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UTM Term

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UTM Medium

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Ad Group ID

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Gclid

Part 1: Eligibility

Do you have a mental health condition that effects your ability to do daily activities?(Required)

Do you have a mental health condition that impacts your ability to do normal activities at work?(Required)

Are you aged 16 years or over?(Required)

Do you live in England, Scotland or Wales?(Required)

If you are employed, are you earning the National Minimum Wage or above?(Required)

For more information on what the National Minimum Wage is, head to the UK Government website

If you're not sure you are eligible, or would like to refer yourself, call our team on 0300 456 8114.

Someone Else

If you are referring someone else, please confirm you have their consent before going ahead.

If you are referring someone else, please provide your own full name:

Our service is only available to people over 16 who are currently employed, earning over the minimum wage, and have a mental health concern effecting their ability to work. If you believe this applies to you, please review your answers and resubmit the form.

Part 2: Your details

Title(Required)

First name(Required)

Surname(Required)

National Insurance Number(Required)

Date of birth(Required)

Gender(Required)

Ethnicity(Required)

Do you receive Incapacity Benefit, Employment and Support Allowance or Income Support?(Required)

Yes

No

Home address(Required)

Home phone number(Required)

Mobile phone number(Required)

Email(Required)

Preferred contact method(Required)

How did you hear about this service?(Required)

If other - please state

Part 3: Your job details

What is your job title?(Required)

When did you start your current job? Provide the approximate month & year (eg. 08/21)(Required)

Unique Tax Reference number (UTR) if you are self-employed

What is the name of your employer?(Required)

Workplace address(Required)

Size of employer – number of employees(Required)

Small: 1 - 49 employees

Medium: 50 - 249 employees

Large: 250+ employees

Please select your employment sector from this list(Required)

If other - please state

How many hours do you work in a normal week?(Required)

What is your normal working pattern? (eg. Monday to Friday, 09:00 – 17:00)(Required)

Are you currently attending work?(Required)

Can you tell us a sentence or two about your role and duties?(Required)

Part 4: Your mental health concerns

Your main mental health concern(Required)

If other - please state

Please tell us in a couple of sentences the effect that your mental health concern has on your ability to do your job(Required)

Is there anything specific you are finding difficult at work? For example, deadlines or group projects?(Required)

Does your employer provide any support around mental health, and how is your relationship with your employer?(Required)

Is there any other information regarding your work situation you would like to tell us about?(Required)

Do you receive any other support outside of work for your mental health?(Required)

Do you require any additional support to participate in an appointment? For example, an interpreter if you are hearing impaired(Required)

Consent

I agree to receive other communications from Maximus.

Maximus is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:

You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.

By clicking submit below, you consent to allow Maximus to store and process the personal information submitted above to provide you the content requested.