Fill out
our form
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Step 1 of 4 - Eligibility

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Part 1: Eligibility

Do you have a mental health concern that has an effect on 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?*(Required)

For more info on what the National Minimum Wage currently is, head to the government website

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

Someone Else

If someone else, please confirm you have consent from the individual before proceeding.

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)

Last Name(Required)

National Insurance Number(Required)

Date of birth(Required)

Gender(Required)

Ethnicity(Required)

Are you receiving Incapacity Benefit, Employment and Support Allowance or Income Support?(Required)

Home address(Required)

Postal code(Required)

County(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 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.

About the service

We can help you manage conditions such as anxiety, depression and stress at work.

About this form

This form tells us more about you and takes 10 minutes to complete. It's 100% confidential.

Your information

Your personal information is important to us and won't be shared with third parties.

Make your mental health a priority

We know that everyone's mental health journey is different, and we are committed to helping you feel happier and healthier in the workplace, at no cost to you.

Fill out
our form
to get support

Part 1: Eligibility

Part 2: Your details

Part 3: Your job details

Part 4: Your mental health concerns

About the service

About this form

Your information

Make your mental health a priority

Part 1: Eligibility

Part 2: Your details

Part 3: Your job details

Part 4: Your mental health concerns

Fill out our form to get support

Part 1: Eligibility

Part 2: Your details

Part 3: Your job details

Part 4: Your mental health concerns

Let's keep in touch!

Thank you!

About the service

About this form

Your information

Make your mental health a priority

Part 1: Eligibility

Part 2: Your details

Part 3: Your job details

Part 4: Your mental health concerns

Fill out
our form
to get support