Coaching Application Form The Coaching Service provides information and individual support to clinical trainees and professionals working within the NHS in patient facing or support roles. This support is free and confidential to doctors and dentists training in London and the South East. You will be allocated to a suitable coach who will work with you on the issues identified in your application. Should you have any concerns or issues with this allocation please contact: Coaching.PSULondon@nhs.net Your allocated coach will be in touch within 14 working days to confirm a suitable appointment date. Your application will be treated in the strictest of confidence. We recognise that most people approaching the Coaching Service are not in need of an urgent response, but occasionally people who contact us are extremely distressed about their career, and the wider issues affecting it such as health and relationships, and need somebody to respond quickly. If this is your situation, then we would like to draw your attention to the following resources that are available: Practitioner Health The Practitioners Health Programme will be available or those who need urgent advice re wider issues around their career. Please note that this is not an emergency service; trainees requiring emergency support should contact their GP, A&E or Urgent Care Centre. KSS Foundation & SuppoRTT (SRTT)Trainees KSS Foundation & SupporRTT (SRTT) trainees should access support services via the KSS’s own Professional Support & Wellbeing Service. Please head to https://kss.hee.nhs.uk/kss-foundation/current-doctors-in-training/careers-and-wellbeing-support/ for more information. It's easy to apply for one to one support: simply complete the Coaching Service application form below: Title * - Select -DrMrMrsMsMissProf First name * Last name * Email Address * Gender * - Select -MaleFemalePrefer not to sayPrefer to self-identify I self-identify as Telephone Number * Professional registration * Profession * Doctor Dentist Dietician Nurse Midwife Pharmacist Healthcare Scientist Physiotherapist Radiographer Paramedic Other Other profession Stage of training * - Select -Core TrainingFoundationHigher Specialist TrainingPreceptorshipProbationary TrainingSpecialty TrainingOther Other stage Position/Grade * - Select -CT1CT2FY1FY2ST1GPST1ST2ST3GPST3ST4GPST4ST5ST6ST7ST8 Other position/grade Job title * Medical or dental specialty? * Medical Dental Specialty * - Select -AcademicAcute Care Common Stem - Acute MedicineAcute Care Common Stem - AnaestheticsAcute Care Common Stem - Emergency MedicineAcute Internal MedicineAllergyAnaestheticsAudio Vestibular MedicineCardiologyCardiothoracic SurgeryChemical PathologyChild and Adolescent PyschiatryClinical GeneticsClinical NeurophysiologyClinical OncologyClinical Pharmacology and TherapeuticsClinical RadiologyCommunity Sexual and Reproductive HealthCore Anaesthetics TrainingCore Medical TrainingCore Psychiatry TrainingCore Surgical TrainingDental and Maxillofacial RadiologyDental Core TrainingDental Foundation TrainingDermatologyDiagnostic NeuropathologyEmergency MedicineEndocrinology and Diabetes MellitusEndodonticsForensic PsychiatryFoundationGastro-enterologyGeneral PracticeGeneral PsychiatryGeneral SurgeryGenito-urinary MedicineGeriatric MedicineHaematologyHistopathologyImmunologyInfectious DiseasesIntensive Care MedicineInterventional RadiologyMedical MicrobiologyMedical OncologyMedical OphthalmologyMedical PsychotherapyMedical VirologyNeurologyNeurosurgeryNuclear MedicineObstetrics and GynaecologyOccupational MedicineOld Age PsychiatryOphthalmologyOral and Maxillofacial PathologyOral and Maxillofacial SurgeryOrthodonticsOtolaryngologyPaediatric and Perinatal PathologyPaediatric CardiologyPaediatric DentistryPaediatric Intensive Care MedicinePaediatricsPalliative MedicinePlastic SurgeryProsthodonticsPsychiatry of Learning DisabilityPublic Health DentalPublic Health MedicineRehabilitation MedicineRenal MedicineRespiratory MedicineRestorative MedicineRheumatologySpecial Care DentistrySport and Exercise MedicineStroke MedicineTrauma and Orthopaedic SurgeryUrologyVascular SurgeryOther Other specialty Ethnicity * - Select -White: EnglishWhite: WelshWhite: ScottishWhite: Northern IrishWhite: BritishWhite: IrishWhite: Gypsy or Irish TravellerWhite: Any other white backgroundMixed/Multiple Ethnic Groups: White and Black CaribbeanMixed/Multiple Ethnic Groups: White and Black AfricanMixed/Multiple Ethnic Groups: White and AsianMixed/Multiple Ethnic Groups: Any other mixed/multiple ethnic backgroundAsian/Asian British: IndianAsian/Asian British: PakistaniAsian/Asian British: BangladeshiAsian/Asian British: ChineseAsian/Asian British: Any other Asian backgroundBlack/African/Caribbean/Black British: AfricanBlack/African/Caribbean/Black British: CaribbeanBlack/African/Caribbean/Black British: Any other Black/African/Caribbean backgroundOther Ethnic Group: ArabOther Ethnic Group: HispanicOther Ethnic Group: LatinoOther Ethnic Group: Native AmericanOther Ethnic Group: Pacific IslanderOther Ethnic Group: Any other ethinci groupPrefer not to say Specify ethnicity if not above LETB * - Select -KSSNorth West LondonNorth Central and North East LondonSouth LondonOther Other LETB Do you consider yourself to have a disability? * Yes No Prefer not to say Trust * - Select -Ashford & St Peter's HospitalsBarking and Dagenham CCGBarnet CCGBarnet, Enfield and Haringey Mental Health NHS TrustBexley CCGBrent CCGBrighton and Sussex University Hospital NHS TrustBromley CCGCamden and Islington NHS Foundation TrustCamden CCGCentral and North West London NHS Foundation TrustCentral London (Westminster) CCGCentral London Community Healthcare NHS TrustChemical Incident Response ServiceCity and Hackney CCGCroydon CCGDartford and Gravesham NHS TrustEaling CCGEaling Hospital NHS TrustEast Kent Hospital University NHS Foundation TrustEast London NHS Foundation TrustEast Sussex Healthcare NHS TrustEnfield CCGEpsom and St Helier University Hospitals NHS TrustFrimley Park Hospital NHS Foundation TrustGreat Ormond Street Hospital for Children NHS Foundation TrustGreenwhich CCGGuy's and St Thomas' NHS Foundation TrustHammersmith and Fulham CCGHaringey CCGHarrow CCGHavering CCGHealth Protection AgencyHillingdon CCGHomerton University Hospital NHS Foundation TrustHospiceHounslow and Richmond Community Healthcare NHS TrustHounslow CCGImperial College Healthcare NHS TrustIslington CCGKent and Medways NHS & Social Care Partnership TrustKing's College Hospital NHS Foundation TrustKingston CCGLambeth CCGLewisham CCGLondon Regional Health Protection AgencyMaidstone and Tunbridge Wells NHS TrustMedway NHS Foundation TrustMoorfields Eye Hospital NHS Foundation TrustNewham CCGNorth East London NHS Foundation TrustNorth Middlesex University Hospital NHS TrustNorth West London Hospitals NHS TrustOxleas NHS Foundation TrustPublic Health EnglandQueen Victoria Hopsital NHS Foundation TrustRedbridge CCGRichmond CCGRoyal Brompton and Harefield NHS Foundation TrustRoyal Free London NHS Foundation TrustRoyal National Orthopaedic Hospital NHS TrustRoyal Surrey County Hospital NHS TrustSouth London and Maudesley NHS Foundation TrustSouth London Healthcare NHS TrustSouth West London and St. George's Mental Health NHS TrustSt George's Healthcare NHS TrustSurrey & Borders Partnership TrustSurrey & Sussex Healthcare NHS TrustSutton CCGTavistock and Portman NHS Foundation TrustThe Hillingdon Hospitals NHS Foundation TrustThe Lewisham Healthcare NHS TrustThe Royal Marsden NHS Foundation TrustThe Whittington Hospital NHS TrustTower Hamlets CCGUniversity College London Hospitals NHS Foundation TrustWaltham Forest CCGWandsworth CCGWest London (K&C &Qpp) CCGWest London Mental Health NHS TrustWest Sussex Hospitals NHS TrustOther Other trust Place of Primary Qualification * UK IMG (International Medical Graduate) What is your current training position? * In training In training within 3 months of taking an OOP Taking an OOP Returned to training within the last 3 months (potentially as part of a Supported Return to Training Programme (SRTT) Please indicate your general availability for appointments * What do you hope to achieve or clarify through accessing one to one coaching? * Please tell us about your main concerns or reasons for applying to The Coaching Service * Please provide any other details which may help us when allocating a suitable coach to work with you * From 2024 our normal process is not to telephone triage one to one Careers and Coaching applications. By ticking the first box below, you agree that the first triage call is not necessary. However if you feel this would be beneficial to you please tick the second box below and you will be sent an appointment time. I do NOT require a telephone triage call and understand that a coach will be allocated and will contact me directly to arrange a first session I prefer to have a telephone triage call Appointment Type * - Select -General Coaching AppointmentSupported Return to Training (SRTT) Coaching AppointmentOther How did you hear about the Coaching Service? * ARCP Educational/Clinical Supervisor TPD/Line Manager Friend/Colleague who has used the service PG Dean Other PSU Service (please tick below) Other Have you or are you intending to also submit an application for careers coaching (if appropriate)? Please note that careers and coaching applications from the same applicant will be considered jointly before appropriate allocation. * Yes No Have you accessed or applied to any other services in PSU previously? * CareersCoaching ServiceIndividual Support Team (IST)Professional Support Unit (PSU)Supported Return To Training (SRTT)None Consent Type * Yes No If you have been signposted to Careers by another PSU service listed above, please indicate whether you understand and consent that a further triaging conversation can be bypassed, and a coach will be allocated to contact you to arrange the first appointment Confirmation * By clicking here you will confirm that you have accepted the terms of our privacy statement. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. What code is in the image? * Submit