SEL Mind Workshop Registration Form 2023/24

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* 1. Please tell us your full name.

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* 2. Would you like to attend the "What is Neurodiversity?" workshop. 15th July 2024 6pm - 8pm

Yes

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* 3. Would you like to attend our Anger Management workshops (Part 1 and 2)? (currently unavailable)

Yes

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* 4. Would you like to attend our Anxiety workshops (Part 1 and 2) (currently unavailable)?

Yes

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* 5. Would you like to attend our Intimacy workshops (Part 1 and 2) (currently unavailable)?

Yes

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* 6. Would you like to attend our Health and Wellbeing workshops (Part 1 and 2)? (currently unavailable)

Yes

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* 7. What is the name of your organisation? (if applicable)

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* 8. Please tell us your email address.

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* 9. Please tell us your phone number

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* 10. Which borough do you live in?

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* 11. Which borough do you work in?

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* 12. Gender

Male

Female

Transgender

Other (Non Binary)

Prefer not to say

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* 13. Age Bracket

18-24

25-34

35-44

45-54

55-64

65+

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* 14. Ethnicity

Black Caribbean

Black African

Other Black background including Black British

White and Black Caribbean

White and Black African

Other Mixed Background

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* 15. Sexual Orientation

Heterosexual

Gay

Bisexual

Lesbian

Asexual

Other

Prefer not to say

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* 16. Faith/Beliefs

Christian

Buddhist

Muslim

Jewish

Spiritualism

Other (Incl non organised religion)

No Religion

Prefer not to say

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* 17. Disability information

No Disability

Physical/Mobility Impairment

Visual/Hearing Impairment

Learning Difficulties

Long Term Condition/Illness

Mental Health Condition

Memory Impairment

Other (Incl Anxiety, Depression, Diabetes

Registered Disabled

Prefer not to say

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* 18. Referral Organisation

BLG Mind

Lewisham Talking Therapies

Lewisham Council

Black Community Organisation

Counsellor/Therapist

Mabadiliko CIC

Self Referral

Other (please specify)

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* 19. I would like to receive email updates from Mabadiliko CIC about upcoming events and information

Yes