Mental Health PACE Setter Award

Sign-Up Form

Your Primary Care / Community Provider details:

Name and Title of Key Contact (of person completing this form)
Telephone No
Email Address

Details about your Service:

Name of Primary Care / Community Provider
Names of Core Team making the Mental Health PACE Setter Application (eg Lead Clinician,Practice Nurse, Practice Manager etc)
Tell us a little about your practice population and characteristics (in brief)
Tell us about the scale (population size including of patients with mental health needs where known), scope, practice set up, mental health best practice, mental health challenges, desired impact and any other notable features.
Tell us a little about your staff team? (Including consideration of the whole team e.g. receptionists, clinicians – GPs, locums, nurses, etc.)
Why does your team want to join the Mental Health PACE Setter Pioneer Programme?
How did you hear about the Mental Health PACE Setter Award?
Are you willing to share lessons learned / best practice (as these form a key feature of our initiative)?
Evaluating the Mental Health PACE Setter information and process (eg Inspiration Guide, website etc) for potential wider roll out (post pioneer phase) is part of the testing. Therefore, we will value your detailed assessment and feedback on this. Thank you / Are you willing to provide feedback as the project unfolds?
Yes / No

Statement of Intent:

On behalf of my organisation, ______(insert your name) is applying to be part of the Mental Health PACE Setter Awardpilot and wish to apply for the funding that is attached to this scheme. The funding is £1,000 inclusive per practice / provider for the whole duration of the project. This money will be paid over as £750 at the beginning (post the Introduction Meeting) and the remaining £250 at completion of the PACE Setter Award UK Application.We, as a core Primary Care / Community Provider team, commit that we will complete the Award process and be willing to share our best practice and lessons learned with the wider health community.

Name (Block Capitals) / Job Title
Signature / Date
Next Step:
Please send the completed form to Anne Johnson: . We will then be in touch to arrange the introductory meeting. Any queries please call Anne on 01903 277008.

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