Intimacy Workshop Registration

1.Please tell us your full name.(Required.)
2.What is your email address?(Required.)
3.What is your phone number? (Required.)
4.Do you live in the London Borough of Lewisham?(Required.)
5.What is the first part of your postcode e.g. SE6(Required.)
6.Which of the following genders do you identify with?(Required.)
7.Which age category best applies to you?(Required.)
8.Which ethnicity best applies to you?(Required.)
9.What is your sexual orientation?(Required.)
10.What is your faith?(Required.)
11.Which date would you like to attend?
12.Do you have any of the following disabilities or conditions (please select all that apply)(Required.)
13.What is your referral route?(Required.)
14.How did you hear about us?(Required.)
15.Difficulty with Intimacy regularly impacts my life in a negative way.(Required.)
16.I am able to recognise signs and symptoms when I find intimacy difficult. (Required.)
17.I am able to manage the symptoms when I find intimacy difficult.(Required.)
18.I know where to access support when I need help with intimacy.(Required.)
19.What are you hoping to achieve from taking part in the Intimacy workshop (please select all that apply)(Required.)
20.In your own words, please tell us what you hope to achieve by joining the Intimacy workshop.(Required.)
21.I would like to receive email updates from Mabadiliko CIC(Required.)
Current Progress,
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