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Title * - Select -DrMrMrsMsMissProf First name * Last name * Email Address * Gender * - Select -MaleFemalePrefer not to sayPrefer to self-identify I self-identify as: * Telephone Number * GMC / GDC / NMC / other Registration Number * 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) Reason for requesting one-to-one appointment * Psychological/emotional difficulties/stress/burnout Struggling with clinical workload Returning to training Dealing with more complex clinical scenarios/working outside usual scope of practice Difficulty with colleague Difficulty addressing problems in current team/unit/system Advice regarding progression of training/career pathway Demands/pressures related to life way from work (including family, finances, friends) Personal ill-health Other Other (please specify) * Have you ever been in contact with the PSU prior to this application? 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