NHS Kent, Surrey and Sussex Leadership Academy

Coaching and Mentoring Scheme

Register as a coach

To register as a coach, please complete this form, filling in the requested information or ticking the boxes. The more information you provide, the easier it will be for the right people to find your profile.

To move between sections, click 'Next' or the required tab. When you have completed all sections, please click 'Submit my application now'.

nb. please do not use your browser's 'Back' and 'Forward' buttons, otherwise you may lose information that you have entered.

About you

Please tell us some details about yourself.

* denotes a required field

Title  
First name *
Last name *
E-mail address *
Organisation *
Job title *
Address line 1 *
Address line 2
Address line 3
Town *
County *
Postcode *
Telephone number *
Alternative telephone number
Clinical background *
Consent to storage and use of your personal data *

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Coach details

Please provide the following details specifically with regard to your eligibility to register as a coach and to your coach profile.

* denotes a required field

Supervision received?   
Please specify your supervision provider and date of your most recent supervision:
Provider:
Date:
Time:
:
Duration:
Coaching qualification(s), level and date(s) qualified *
Clinical status
Coach comments
What level of staff are you happy to provide coaching for? *
I have experience in and am willing to work with someone to help them *
I am willing to enter into a coaching relationship that is *
I am willing to work within the following geographical area *
I would prefer my coaching to take place via *
Interests in coaching *
Coaching experience *
Any other useful information
Are you a Healthcare Leadership Model (HLM) 360 feedback facilitator? *
Supervision requirements *
CPD requirements *
Number of coaching relationships I am willing to have at any one time *
 
Supporting document
e.g. biography, record of contractual agreement – optional (Word, Excel or PDF files accepted)

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Diversity & Inclusion

The following questions are for D&I monitoring purposes only, and the information provided will not be made available to other users:

* denotes a required field

Gender identity. Which of the following options best describes how you think of yourself?  *
Is your gender identity the same as the gender you were given at birth? *
Your age group *
How would you describe your ethnic origin? *
Your religion or belief *
Which of the following options best describes how you think of yourself? *
Do you consider yourself to be a disabled person as defined by the Equality Act 2010? *
If you consider yourself to be a disabled person, and would like to, please indicate the nature of your disability (tick as many as are applicable)
Other disability - please specify

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Coaching agreement

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CRBhub Coaching Hub is based on the CRBhub management system from CRB Associates