Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

Are you happy for us to contact you regarding your application?

By post

By email

By mobile

By text message

Other information

About you

Date of birth

Age

Ethnicity

Nationality

Sex

Faith

Your Discipleship journey so far

The discipleship principles below are the same ones that you will learn about as part of the support programme you are applying for.

To help assess your discipleship needs, please indicate your current levels of confidence in applying each of the discipleship principles to your life.

Our Discipleship Curriculum

At Mercy UK, we are transparent in our approach to offering support and guidance that is centred around, and founded upon, Christian belief and practice.

Our support includes offering Bible-based discipleship, teaching and prayer whilst respecting the right for individuals to self-govern in accordance with their own beliefs and values.

This means our support will always signpost you back to your own personal relationship with God.

Statement of Faith Document: https://drive.google.com/file/d/1N0RmXuDzDoquqhSW73RbLWrpJuaSJuZ0/view?usp=sharing

Your faith

How would you describe your relationship with Father God?

How would you describe your relationship with Jesus?

How would you describe your relationship with the Holy Spirit?

What would you like to see happen in your life as a result of being able to access support and discipleship from Mercy UK?

Are you part of a local church or Christian fellowship?

We have learned that long-term success really does depend on having a solid support network as part of a local church community or Christian fellowship.

If you are not already part of a church community or Christian fellowship when you apply,.

we will always aim to connect you with a local church or a Christian fellowship to facilitate a local support network for you and the nomination of an accountability partner, where needed.

If yes, please specify the name, address and contact of the church and your pastoral leader. (The Admissions team will NOT contact your church or pastoral leader without your permission.)

Your physical health

Where beneficial to the participant, individual sessions with a trained specialist such as a nutritionist, personal trainer or occupational therapist, will be facilitated.

By telling us about your physical health and wellbeing, we are able to assess the most suitable support for your needs.

Please tell us your weight

Please tell us your height

Do you have any physical limitations and/or medical conditions that affect your day to day life?

If yes, please specify details

Such as: asthma, migraines, anaemia, chronic fatigue, diabetes, digestive tract problems, blood pressure problems, heart problems, etc.

Such as: asthma, migraines, anaemia, chronic fatigue, fibromyalgia, diabetes, digestive tract problems, blood pressure problems, heart problems, etc.

Are you currently taking any prescription medication that support your mental health? (For example: antidepressants, anti psychotics, mood stabilisers.)

If yes, please specify the name of medication, dosage and reasons for prescription

Do you currently use or have you ever used illegal drugs?

If yes, please specify type of drug, duration and degree of misuse and approximate date you last used

Do you currently misuse or have you ever misused alcohol?

f yes, please specify type of alcohol, duration and degree of misuse and approximate date you last drank in excess

Do you currently misuse or have you ever misused either prescribed or over-the-counter medication?

If yes, please specify name of medication, duration and degree of misuse and approximate date you last used?

Do you think you would benefit from physical health and fitness support?

Do you currently or have you ever struggled with disordered or imbalanced eating habits such as with-holding food, binging, purging or compulsive over-eating?

If yes, please specify the nature and duration of your struggles

Have you ever been diagnosed with any form of eating disorder or body dysmorphia?

If yes, please specify the diagnosis, when this was given and by whom.

Your General Wellbeing & Support Needs

Do you experience any challenges with reading, writing or comprehension?

If yes, please specify the nature of the challenges and any diagnosed learning difficulties

Do you currently experience, or have received a diagnosis or assessment in any form, of neurodiversity such as ADHD, Autism or ASD?

If yes, please specify the nature of your neurodiversity, any assessments received and any limitations you experience

Within the last 2 years, have you received any professional counselling, care or support?

If yes, please specify the nature of professional support, the duration of the support and the approximate date you last accessed this support

If you have received any formal mental health support in the last 2 years through a GP, therapist, counsellor or pastoral lead, please list the full names and addresses of each of these individuals

Have you ever received a mental health diagnosis?

If yes, please specify the diagnosis you received, when this was given and by whom?

Would you benefit from any debt management support?

Your Personal Experiences

Have you ever been subject to emotional abuse / mistreatment?

Have you ever been subject to physical abuse / mistreatment?

Have you ever been subject to sexual abuse / mistreatment?

If yes and you feel confident, can you briefly summarise your experience?

Have you experienced a traumatic event such as an accident, war or act of terror or crime?

Have you ever been subject to spiritual or religious control or abuse?

If yes and you feel confident, can you briefly summarise your experience?

Do you currently or have you ever struggled with suicidal thoughts or attempts?

Other, details

Do you currently or have you ever struggled with self-harm?

Other, details

Have you ever been arrested or convicted of a criminal offence?

If yes, please specify charge, date of charge and whether you were convicted

Are you currently involved in any legal preceedings or pending court dates?

If yes, please specify

Emergency Contact Name and Telephone Number

Declaration

By ticking each box, you agree the following

I confirm that I have not willingly withheld information that could be relevant to my application

I understand that the information I have provided is confidential between Mercy UK and myself and information will not be shared by Mercy UK without my expressed permission.

Enter your name to signifiy your agreement

Application form