1

Reference Group to the office of Service User, Family Member and

Carer, Mental Health Services:

Application Form

CONFIDENTIAL

Please ensure you complete all areas of the application form in full. Failure to
complete all areas of the application form may result in your application not being
brought forward to the selection stage.

Please ensure that your completed Application Form reaches Valerie Greville no later
than 5pm Monday 30
th
June 2014

By email: Valerie.greville1@hse.ie

By post: Mental Health Division, HSE, Oak House, Millennium Park, Naas, Co
Kildare.

Applications received after this date and time will not be accepted.

Please read the attached specification which provides useful information about the
requirements of the Reference Group.

PERSONAL DETAILS
Please use capitals letters
SURNAME : CONTACT ADDRESS:
FIRST NAME:

PHONE:

EMAIL:
PLEASE INDICATE IF YOU ARE:

A SERVICE USER
A FAMILY MEMBER
A CARER









2





Please provide details below of your active role or involvement with a mental health
organisation (e.g. fundraising, participating in social events, self help groups)








































Introduction to SKILLS AND ABILITIES

THE FOLLOWING SECTION FOCUSES ON THE KEY SKILLS AND ABILITIES REQUIRED FOR THE
RERERENCE GROUP ROLE

You are asked to give examples from your past experience that demonstrate your suitability
for the Reference Group role. When answering this section you may give examples either from
work or from outside of work (e.g. home, leisure, educational, training or voluntary activities).
When answering this section:

Make it personal: focus on your involvement in the example given
Give examples of things you did, not things you were just aware of
Answer all the follow up questions within each section
Refer to the guidance notes provided to assist you in filling out the form

Selection for the Reference Group will be made on the basis of information provided
in your application.
3



Please complete the 4 sections below;

1. IDENTIFYING BETTER WAYS OF DOING THINGS: Members of the Reference Group
need to be able to identify better ways of doing things. This involves analysing the efficiency
of existing practices, making suggestions for improvements, gathering ideas from other people
etc.

Please give an example of a situation where you identified a better way of doing
something. Please include:
How you identified the need for change, what you did, the benefits and risks involved
(personal or other) and the outcome.























2. TEAMWORKING: Members of the Reference Group need to work co-operatively with
others as part of a team. This includes actively supporting and consulting with team members.

Please give an example of a time when you worked as part of a team to achieve a
specific objective:
What was the team trying to achieve, what worked well, what role you played, how you
overcame any difficulties encountered within the team and what you learned regarding
teamworking



















4


3. ADVOCATING FOR CHANGE: Members of the Reference Group will need to be able to sell
change. This involves persuading people to take ideas on board. In some instances it may also
require overcoming resistance to change.

Please give an example of a situation where you best demonstrated your ability in
this area. Please include:
What you were aiming to achieve, what steps did you take to bring other people along
with you, the outcome and what you learned in relation to influencing others?
_________________________________________________________________________



















4. Please tell us why you want to be a member of the Reference Group (200 words or
less)






















Signed: ___________________________

Print name: ___________________________

Date: ___________________________