Well-Being Assessment FormWell-Being Assessment FormAdditional confidential support is available to anyone who would like to talk to us - this can be about any issues surrounding your course or personal life. This free and confidential service offers impartial support and guidance on anything that can affect you from difficulties at home to mental health.If you would like our Learner Support Team to contact you to discuss any of these issues confidentially please indicate below or you can contact the team on 01752 202263 / 07497 413181.The information you disclose on this form will be seen only by staff that are here to support you. Our aim is to offer holistic support and guidance with any difficulties that you might experience in your life, both inside and outside of your education.Learner NameLearner Date of Birth (Optional):Curriculum Department:- Select -Animal CareBusiness Support ServicesChildcare and EducationEmployment and ProgressionHair and Beauty CentralHealth and Social CareTeaching and Learning1 . Would you like support/guidance on any safeguarding concerns or other difficulties affecting your life?- Select -YesNoMaybe in the future2 . Would you like support or guidance regarding relationships with your parents/guardian/partner or others that you live with?- Select -YesNoMaybe in the future3 . Would you like any support or guidance on any issues around your mental health and emotional well-being?- Select -YesNoMaybe in the future4 . Do you feel you have a strong support network (e.g. friends, family, etc.)?- Select -YesNoSometimes (Please explain below)Please provide more details relating to how you feel about your support network:5 . In general, where would you score yourself with your confidence and self esteem? (0- Low self esteem/ 10 - High self esteem)56 . Apart from your training, is there anything else we can support you with?- Select -YesNoMaybe in the futurePlease use this space if you would like to request support and / or provide further information:Would you like to be contacted by a member of Learner Support to discuss any of the above? Yes NoIf you were to be contacted, what is your preference? Email Text PhonePlease provide email address:Please provide telephone number:Learner Signature: Sign HereSubmit Form