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Home > Wellbeing Colleges > North Somerset Wellbeing Booking Form

North Somerset Wellbeing Activities, Workshop and Course Booking Form

North Somerset Wellbeing Service is for adults living in North Somerset, or who are registered with a GP in North Somerset, and who are having difficulties with their mental health and wellbeing.

We run a programme of workshops, courses and activities, using wellbeing college style techniques. These group sessions help people to learn to manage their mental wellbeing, and work towards their own recovery goals. We have a range of options that are run in-person or online. Our timetable can be found here.

Please note, our service may not be appropriate for people who are acutely unwell, or who pose a significant risk to themselves or others, or those whose primary difficulties are related to substance or alcohol misuse. If any of these apply to you/the person you are booking on behalf of, please contact us to discuss this further.

Contact us

If you would like to speak to us before completing this form, please email NSWellbeing@second-step.co.uk or call us on 0333 0233 504.

North Somerset Booking Form

1. Type of booking *

Section 1

1. Full name *

2. Date of Birth (over 18yrs*) *

3. Address *

3. Address

Town or City

County

Postcode

4. Telephone Number (Please note calls from our service may come from a ‘withheld’ number) *

5. Email (If you are interested in our online options it is essential to provide your email address.) *

6. GP Surgery *

7. GP Contact Number *

8. What sessions would you like to book? (hold CTRL & click to choose multiple) *

9. Do you have any additional support needs e.g. accessibility, sight impairment, large print *

Yes, please give detailsYes, please give details

10. Preferred method of contact (tick all that apply): *

Telephone

Voicemail

Text Message

PostPost

11. Would like to bring someone along to support you at the session? *

Yes

If you answered yes above please provide their name, role/relationship and contact details

Do we have your consent to share information with this person

Yes

12. Where did you hear about us? *

Equality and diversity information

Gender * Gender

Do you consider yourself to be disabled? * Do you consider yourself to be disabled?

Ethnicity * Ethnicity

Sexuality * Sexuality

Gender the same as registered at birth * Gender the same as registered at birth

Pregnant * Pregnant

Religion/Belief * Religion/Belief

Relationship Status *

Section 2. To be completed by third-party referrals only

14. Full name of referrer *

15. Professional role of referrer *

16. Organisation role of referrer *

17. Telephone number of referrer *

18. Email of referrer *

19. Is the person you are referring aware of this referral and given you consent to refer? *

Yes

20. Would you like to be kept up to date with the outcome of your referral? *

Yes

Dropdown

Phone

Dropdown

If you are human, leave this field blank.

Using your information

At Second Step, protecting your personal information is very important to us and we will ensure your personal data is kept confidential and held securely.

We use a great deal of information in our services. For example, we process information about current and past service users working with us or receiving support or tenants in our accommodation. For each service Privacy Policies will be presented directly to these individuals in an upfront way, to ensure they clearly understand how we will use their information.

To find out how we use, store and protect information obtained for these purposes please read our
protecting your personal information leaflet [opens as a PDF]