Mabadiliko Mental Health Workshop Registration Form 2023/24
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1.
Please tell us your full name.
(Required.)
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2.
Would you like to attend the "
What is Neurodiversity
?" workshop. 15th July 2024 6pm - 8pm
(Required.)
Yes
No
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3.
Would you like to attend our
Anger
Management
workshops (Part 1 and 2)? (currently unavailable)
(Required.)
Yes
No
*
4.
Would you like to attend our
Anxiety
workshops (Part 1 and 2) (currently unavailable)?
(Required.)
Yes
No
*
5.
Would you like to attend our
Intimacy
workshops (Part 1 and 2) (currently unavailable)?
(Required.)
Yes
No
*
6.
Would you like to attend our
Health and Wellbeing
workshops (Part 1 and 2)? (currently unavailable)
(Required.)
Yes
No
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7.
What is the name of your organisation? (if applicable)
(Required.)
*
8.
Please tell us your email address.
(Required.)
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9.
Please tell us your phone number
(Required.)
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10.
Which borough do you live in?
(Required.)
11.
Which borough do you work in?
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12.
Gender
(Required.)
Male
Female
Transgender
Other (Non Binary)
Prefer not to say
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13.
Age Bracket
(Required.)
18-24
25-34
35-44
45-54
55-64
65+
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14.
Ethnicity
(Required.)
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
(Required.)
Heterosexual
Gay
Bisexual
Lesbian
Asexual
Other
Prefer not to say
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16.
Faith/Beliefs
(Required.)
Christian
Buddhist
Muslim
Jewish
Spiritualism
Other (Incl non organised religion)
No Religion
Prefer not to say
*
17.
Disability information
(Required.)
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
*
18.
Referral Organisation
(Required.)
BLG Mind
Lewisham Talking Therapies
Lewisham Council
Black Community Organisation
Counsellor/Therapist
Mabadiliko CIC
GP
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
(Required.)
Yes
No
Current Progress,
0 of 19 answered
