Emotional Support Group Registration - For Survivors of Domestic Violence and Abuse
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1.
Please tell us your full name.
(Required.)
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2.
What is your email address?
(Required.)
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3.
Which phone number can the group facilitator contact you on? (Preferably a mobile phone number)
(Required.)
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4.
Do you live or work the borough of Lewisham?
(Required.)
Yes
No
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5.
What is the first part of your postcode e.g. SE6
(Required.)
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6.
Which of the following genders do you identify with?
(Required.)
Male
Female
Trans-gender
Non-Binary
I'd prefer not to say
Other (please specify if you wish)
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7.
Which age category best applies to you?
(Required.)
18-25
26-35
36-45
46-55
56-65
66-75
76-85
86+
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8.
Which ethnicity best applies to you?
(Required.)
Black Caribbean
Black African
Other Black background incl Black British
White and Black Caribbean
White and Black African
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9.
What is your sexual orientation?
(Required.)
Heterosexual
Gay
Bisexual
Lesbian
Asexual
Prefer not to say
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10.
What is your faith?
(Required.)
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Other (non-organised religion, Pagan, other religions)
No Religion (atheist, agnostic, no religion)
Prefer not to say
11.
What date would you like to attend?
16th March 2023 - 6pm to 8pm
6th May 2023 - 11am to 1pm
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12.
Do you have any of the following disabilities or conditions (please select all that apply)
(Required.)
No Disability
Physical/Mobility Impairment
Visual / Hearing Impairment
Learning Difficulty
Long Term Condition / Illness
Mental Health Condition
Memory impairment
Registered Disabled
Prefer not to say
Other (incl. Depression, Anxiety, Diabetes)
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13.
What is your referral route?
(Required.)
Self-Referral
IAPT Referral
BLG Mind referral
GP Referral
Mabadiliko CIC Referral
Referral from another Black-led Community/ Voluntary Group
Other (please specify)
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14.
How did you hear about us?
(Required.)
Mabadiliko CIC
Word of mouth
WhatsApp
Blue Print For All
South Lewisham PPG
Lewisham BME Network
Lewisham Local
Other (please specify)
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15.
My emotional and mental wellbeing regularly impacts my life in a negative way.
(Required.)
1 - Strongly Agree
2 - Agree
3 - Disagree
4 - Strongly Disagree
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16.
I am able to
recognise
signs and symptoms of poor emotional and mental wellbeing.
(Required.)
1 - Strongly Agree
2 - Agree
3 - Disagree
4 - Strongly Disagree
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17.
I am able to
manage
the symptoms of poor emotional poor emotional and mental wellbeing.
(Required.)
1 - Strongly Agree
2 - Agree
3 - Disagree
4 - Strongly Disagree
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18.
I
understand
where to access support when I need help with my emotional and mental wellbeing.
(Required.)
1 - Strongly Agree
2 - Agree
3 - Disagree
4 - Strongly Disagree
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19.
Are you currently experiencing domestic abuse?
(Required.)
Yes
No
I'd prefer not to say
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20.
I feel confident talking about my experience of domestic violence and abuse.
(Required.)
1 - Strongly Agree
2 - Agree
3 - Disagree
4 - Strongly Disagree
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21.
I understand the impact of domestic violence and abuse on relationships.
(Required.)
1 - Strongly Agree
2 - Agree
3 - Disagree
4 - Strongly Disagree
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22.
I understand the impact of domestic violence and abuse on myself (and any children) as survivors.
(Required.)
1 - Strongly Agree
2 - Agree
3 - Disagree
4 - Strongly Disagree
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23.
I experience feelings of shame, guilt or self-blame as a result of domestic violence and abuse.
(Required.)
1 - Strongly Agree
2 - Agree
3 - Disagree
4 - Strongly Disagree
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24.
What are you hoping to achieve from taking part in the Emotional Support Group (please select all that apply)
(Required.)
Routine /Structure to life
Reduce social isolation
Learn new skills
Improve quality of life
Social activity
Meet new people
Support/Engaged in the Community
Moving into paid employment
Other / No information given
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25.
In your own words, please tell us what you hope to achieve by joining the Emotional Support Group for survivors of domestic violence and abuse.
(Required.)
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26.
I would like to receive email updates from Mabadiliko CIC
(Required.)
Yes
No
Current Progress,
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