*1.What is your full name(Required.)

*2.What is your date of birth?(Required.)

*3.What is your ethnicity? (Please select all that apply.)(Required.)

White English

Any other White background

Welsh

Scottish

Northern Irish

British Irish Gypsy or Irish Traveller

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed or Multiple ethnic background

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian

African

Caribbean

Any other Black, African or Caribbean background

Arab

Other (please specify)

*4.What is your gender?(Required.)

Female

Male

Other

*5.What is your preferred way of contact?(Required.)

By email

By phone

No preference

*6.What is the best email to contact you on?(Required.)

*7.What is the best phone number to contact you on?(Required.)

8.We will be collecting your data and following GDPR guidelines and regulations. The data will be used to create a service that best supports the Muslim community. We can only accept your registration of interest if consent is given. Do you consent to your data being used?

Yes

No

9.Thank you for taking the time out of your day to fill in this survey.

The data you have given us will be used to best shape our mental health peer to peer support service which will be running from the 29th of July 2023 - 29th July 2024.

Please tick this box to confirm you are happy for us to add you to our mailing list as this will contain the details regarding our running times, which group will be running on the Saturday of that month and for you to keep up to date as to any developments with our service.

Yes

No