Coaching Hub : NHS London Leadership Academy

About you
Coachee details
Diversity & Inclusion
Agreement

About you

Please tell us some details about yourself.

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Title
First name *
Last name *
E-mail address *
Organisation *	Please specify: This is an NHS organisation
ICS region
Job title *
Work type *
Work band
Telephone number
Consent to storage and use of your personal data *	Please check this box to confirm that you consent to the storage and use of your personal information within the NHS London Leadership Academy Coaching Hub system. The EU GDPR regulation requires us to obtain this consent from you.

Coachee details

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

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Cohort assignment	I have been assigned to / I would like to receive coaching through an academy-specific cohort Executive Coaching Inclusive Coaching Express Coaching (single, one-off session, eg, troubleshooting, crisis situations) Your coaching need - please give a brief outline of the issue you would like to be coached on: Your objective - what would you like to achieve by the end of the 45 minute coaching session? Clinical Leadership Coaching Primary Care Coaching
Any specific coaching requirements *

Cohort assignment

I have been assigned to / I would like to receive coaching through an academy-specific cohort

Any specific coaching requirements *

Matching preferences

Please indicate the offerings that you would be looking for from your coach:

Work type of coach *	Accounting / Finance Administration and Clerical Allied Health Professionals Ambulance Service Team Chief Executives Chief Accountable Officers Chairs Clinical Support Staff Communications and Marketing Community Development Corporate Services Dental Doctor - General Practice (GP) Doctor - Secondary Care Doctor - Other Domestic Services Estate Services Executive Directors / CCG Governing Body Members Family Support Workers Graduate Management Training Scheme (GMTS) Health Informatics Healthcare Science Housing Improvement Information Technology (IT) Management - Finance Management - General Management - HR Management - Operational Management - Other Midwifery Non-Executive Directors and Lay Members Nursing Organisational Development (OD) Operating Department Practice Pharmacy Physician Associates / Assistants Psychological Professional Public Health Social Workers Support Services Training and Development
Professional requirements *	Managerial VSM Board Level (Including Executive Director) Chief Executive Consultant Medical/Dental Nursing and Midwifery Allied Health Professional / Health Care Scientist GP Doctor in training Technical staff Primary Care
Support requirements *	Develop self-awareness Develop own resilience Improve performance and personal effectiveness Develop career direction and plan Manage the transition into a new role Improve relationships with colleagues, team members, and/or stakeholders Better understanding of how to navigate the wider health and social care systems Improve political awareness Better understanding of own leadership capabilities and how to develop them Managing how personal and work-life impact on each other Develop commercial awareness Personal support during a period of organisational change/restructuring Support for service development and improvement Develop skills in leading change and transformation GP Coaching
Geographical locations happy to receive coaching in: *	North Central London North East London North West London South East London South West London
Preferred methods of coaching *	Face to face Telephone / e-mail Virtual, e.g. Skype, video conferencing
Preferred working days *	Monday Tuesday Wednesday Thursday Friday Saturday

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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:

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Gender identity. Which of the following options best describes how you think of yourself? *	Woman (including trans woman) Man (including trans man) Non-binary In another way I do not wish to disclose
Is your gender identity the same as the gender you were given at birth? *	Yes No I do not wish to disclose
Your age group *	Under 20 20-29 30-39 40-49 50-59 60+ I do not wish to disclose
How would you describe your ethnic origin? *	British white Irish white White Gypsy Other white White and Black Caribbean mixed White and Black African mixed White and Asian mixed Other mixed Indian Pakistani Bangladeshi Other Asian or Asian British Caribbean African Other Black or Black British Chinese Other ethnic group I do not wish to disclose
Your religion or belief *	Atheism Buddhism Christianity Hinduism Islam Jainism Judaism Sikhism Other No religion I do not wish to disclose
Which of the following options best describes how you think of yourself? *	Heterosexual or Straight Gay or Lesbian Bisexual Other sexual orientation not listed I do not wish to disclose
Do you consider yourself to be a disabled person as defined by the Equality Act 2010? *	Yes No I do not wish to disclose
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)	Dyslexia / learning disability Blind / partially sighted Deaf / hearing impairment Mobility difficulties Personal care Mental health difficulty Unseen disability (e.g. diabetes, epilepsy, asthma) Multiple disabilities Autistic spectrum disorder (incl Asperger's Syndrome)
Other disability - please specify

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Coaching and Mentoring agreement

Please check this box to confirm that you have read and accept the below terms and conditions of use: *

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NHS London Leadership Academy

Coaching Hub

Register as a coachee

About you

Coachee details

Matching preferences

Diversity & Inclusion

Coaching and Mentoring agreement