Mental Health Work Experience Application 18+

Application for mental health work experience placements - January 2025

Form

Please read before completing this application form. Your electronic signature at the end of this form will be verification that you have read this information.

1. We require at least 8 weeks’ notice to enable us to arrange your placement
2. Please be clear with the dates you are requesting to attend
3. Your work experience can only last a maximum of 1 week
4. All elements of this form must be completed
5. You must be 18 years of age or older to gain a placement
6. You may only be allocated one department for the duration of your placement depending on availability
7. If you are successful in gaining a placement, there are some mandatory Aspire E-Learning programmes that must be completed prior to starting your placement. Further details of these will be given to you if your application is successful.
8. To be considered for one of our placement we accept applications in January, May and September. All applications received out of these months will be disregarded

Your application is important to us and we will do our best to accommodate your request, however we do receive large volumes of applications and can’t accommodate everybody. We will only contact you if you are successful in securing work experience with us. We will do this 2-weeks prior to the start date of your placement. It is not necessary to contact us unless you have any queries regarding the confirmed work experience placement. Please ensure you check your spam box regularly as some of our emails may deliver straight into that folder and subsequently you may miss communications from us.

Please be aware that an application for Work Experience does not guarantee a placement, although we will endeavour to support your request.

If you are NOT seeking a placement within mental health then please use the Standard application form.

The application window will close as directed on the main page, please be advised that we may close the application window early if we receive a large volume of requests. This application window allows you to apply for placements during April, May, June & July 2025 only. If you are wanting a placement later in the year, please wait for the next application window in May 2025.

Information sharing - By completing this form, I agree that my information can be accessed by the Careers Team to facilitate an appropriate Work Experience placement based on my request.

The application window will close on Friday 31st January at 16:00

Is this application for your block T-Level placement?(Required)

Yes

No

Please contact your College Tutor to arrange a T-Level block placement with us

Personal Details

First Name(Required)

Surname(Required)

Address(Required)

Street Address Address Line 2 Town/City County Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Telephone(Required)

E-mail Address(Required)

Date of birth *Please note that all applicants must be a minimum of 18 years of age(Required)

DD slash MM slash YYYY

Endorsement or Reference(Required)

In the space above, please provide an email address for an individual who will be happy to endorse your application for Work Experience. This should be a teacher, tutor, Work Coach, colleague or professional, who has known you for 2 years or longer and who is not member of your family. Please note that we will be contacting this person for their verification and your Work Experience application is subject to us receiving confirmation from this individual. The email address provided should be educational or professional, not for example, hotmail or gmail.

Do you have any current medical conditions or health issues we should be aware of that would prevent you from undertaking certain tasks?(Required)

Yes

No

Do not wish to disclose

If 'Yes', please provide details:

Current School/College/University:

*If Applicable*

Year Group:

*If Applicable*

Course of Study (e.g. GCSEs, A-Levels, T-Levels, BSc, etc.):

*If Applicable*

If you are not in education, please tick below:

I am not in education

If you are in employment and not in education, please give details (Job Title and Employer):

How did you hear about this opportunity?(Required)

Careers EventSchool/ CollegeSocial MediaParents/ Carer/ GuardianDWP/ Job CentreOther

If other - please state below

Placement Details

Please select the geographical area where you would like to undertake the placement(Required)

Fleetwood

Preston

Burnley

Placement areas(Required)

Community Neurological Rehabilitation Service – Preston care homes

Community Mental Health Team – Burnley

Older Adult Crisis team - Preston

If your area of interest is not listed above, please state here and we will do our best to organise a suitable and/or an alternative placement for you:

Please select the 'weeks commencing' below as your placement preference dates. Details around days and dates will be established upon confirmation of your placement.

March 2025

Mar 31 to Apr 4

April 2025

Apr 7 to Apr 11

Apr 14 to Apr 18

Apr 21 to Apr 25

Apr 28 to May 2

May 2025

May 5 to May 9

May 12 to May 16

May 19 to May 23

May 26 to May 30

June 2025

Jun 2 to Jun 6

Jun 9 to Jun 13

Jun 16 to Jun 20

Jun 23 to Jun 27

Jun 30 to Jul 4

July 2025

Jul 7 to Jul 11

Jul 14 to Jul 18

Jul 21 to Jul 25

Jul 28 to Aug 1

Choose which days you would prefer(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Is this request linked to your School/ College work experience placement dates?(Required)

Yes

No

If you have an NHS contact/employee within a hospital site who has agreed to support your placement, please state their full name, job title and email address below:

Please briefly outline why you are interested in undertaking a Work Experience Placement (minimum of 100 words)(Required)

Emergency Contact Details

Name of emergency contact:(Required)

Relationship to emergency contact:(Required)

Telephone number of emergency contact:(Required)

Agreement

Work experience applicant to complete. Please sign below to show agreement to the following statements:

1. All the information given on this form is correct;
2. I give consent for the Careers & Engagement Team to store and file this information electronically and on paper;
3. I understand that I have the right to request erasure of this information;
4. I will hold in confidence any information about the employer, staff, patients and patient’s families which I may obtain during the placement;
5. I am aware of the acute nature of the placement environment and that I may be exposed to unexpected situations.

Please print your name as a way of confirming you agree to the above conditions.(Required)

Date(Required)

DD slash MM slash YYYY

Equality, Diversity and Inclusion Monitoring

We collect this information to monitor the diversity of our work experience applicants as part of our effort to ensure that we are accessible to all. You do not need to share any of this information with us but if you do, it can help us to make improvements to how we promote and co-ordinate our work placement opportunities across Lancashire & South Cumbria. If you would prefer not to share this information, please select the 'prefer not to say' option.

Gender(Required)

Female

Male

Non-binary

Gender Neutral

Transgender

I prefer not to say

If you choose to self-describe, please give details below:

Do you have any physical or mental health conditions or illnesses lasting or expected to last for 12 months or more? You’re disabled under the Equality Act 2010 if you have a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on your ability to do normal daily activities." This link gives greater detail - https://www.gov.uk/definition-of-disability-under-equality-act-2010(Required)

Yes

No

Do not wish to disclose

If 'Yes', please provide details:

Disability(Required)

Yes

No

If 'Yes', please provide details:

Learning Disability(Required)

Yes

No

If 'Yes', please provide details:

I would describe my ethnic group as:(Required)

White

Mixed

Asian/ Asian British

Black/ Black British

Chinese

Other

If not listed, please state:

Sexual Orientation(Required)

Bisexual

Gay or Lesbian

Heterosexual or Straight

Prefer not to disclose

A sexual orientation not listed

If not listed, please state:

Are you currently or have been in care of the local authority / foster care?(Required)

Yes

No

Do not wish to disclose

Are you a care leaver?(Required)

Yes

No

Do not wish to disclose

Have you been convicted of a criminal offence, been bound over, warned, cautioned or reprimanded or are you currently the subject of any police investigation?(Required)

Please SelectNoYes

If ‘Yes’, please provide brief details: