Inspiring Progress: improving mental health in BME communities

Booking form

Healthwatch Suffolk and Norfolk and Suffolk NHS Foundation Trust are holding an afternoon event launching their survey report on mental health issues among BME communities, and how to progress improvements.

Thursday 29 October 2015, from 1.30 to 4.30pm
IP-City Centre, 1 Bath Street, Ipswich, IP2 8SD

If you wish to book a place:

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* Please give us your contact details below

Name *: *

Organisation (if applicable)

Address 1 *: *

Address 2:

City/Town:

Postal Code *: *

Email Address *: *

Tel. number *: *

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* Do you have any special requirements?

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* We would like to check whether we are reaching all parts of the community we serve. It would help us to know a little bit about who is attending...please tick as many as apply. This information will only be used to assess whether our promotion of the event has been effective.

I am a member of the public

I am a service user

I am a carer

I work in a related field (e.g. housing, primary care)

I am a member of the foundation trust

I prefer not to say

Other (please specify)

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* What age band are you?

Under 18

19-25

26-35

36-50

51-64

65+

Prefer not to say

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* How would you describe your gender?

Female

Male

Prefer not to say

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* How would you describe your ethnicity?

White British

White Irish or White Other

Black or Black British - Caribbean

Black or Black British - African

Black or Black British - Other

Asian / Asian British - Indian

Asian / Asian British - Pakistani

Asian / Asian British - Bangladeshi

Asian / Asian British - Other Asian

Chinese

Mixed Background - White & Black Caribbean

Mixed Background - White & Black African

Mixed Background - White & Asian Mixed Background -

Other Mixed Background

Prefer not to say

Other (please specify)

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* How would you describe your faith / belief system?

Agnostic

Atheist or no belief

Baha'i

Buddhist

Christian - Church of England

Christian - Catholic

Christian - Methodist

Christian - Other denomination

Christian - Non-denominational

Hindu

Humanist

Jewish

Muslim

Sikh

Spiritual but not belonging to any particular religion

Other (please specify)

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* How would you describe your sexual orientation?

Heterosexual

Lesbian woman

Gay man

Bisexual

Prefer not to say

Other (please specify)

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* Would you describe yourself as having a disability?

Physical disability

Mental ill health

Sensory impairment

Learning difficulty such as dyslexia

Learning disability

Prefer not to say

Other (please specify)