NHS South East Leadership Academy

Coaching and Mentoring Scheme

Register as a coachee

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

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

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 *
If yes, please specify your clinical background
Your profile photo (highly recommended) Please ensure that your photo is under 3MB in size. Rectangular photos will be cropped to square.
How did you hear about the coaching register?
Consent to storage and use of your personal data *

Coachee details

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

* denotes a required field

Cohort assignment
Any specific coaching requirements / comments

Matching preferences

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

My current position *
I require a coach to work with me to assist with *
I am willing to enter into a coaching relationship that is *
I would prefer my coach to be based within the following geographical area *
I would prefer my coaching to take place via *

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

Coaching agreement


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