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* 1. Are you:

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* 2. Why do you (or the person you are enquiring for) want or need to do the program? (Please tick all that apply).

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* 3. Why do you (or the person you are enquiring for) want to do the program online and not in a face to face group? (Please tick all that apply).

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* 4. My capacity to pay to attend the program based on my income would be (please tick one):

About You
(If you are not the person wanting to do the program, please answer these questions to the best of your ability on their behalf)

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* 5. Details

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* 6. Your relationship status (please tick all that apply):

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* 7. Do you have any children?

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