Mabadiliko CIC - Expression of Interest Form 2023/24

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* 1. Please tell us your full name.

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

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* 3. Please tell us your email address.

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* 4. Please tell us your phone number

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* 5. Which service/ emotional support are you interested in?

General Emotional Support Group

Anger Management Workshops

Anxiety Workshops

Intimacy Workshops

Health and Wellbeing Workshops

Cultural Humility/ Anti-racism

Research Commissioning/ Partnership

Research Participation

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* 6. I am also interested in the following:

I am interested in volunteering with Mabadiliko CIC

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* 7. Please tell us a little more about you area of interest (optional).

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* 8. Which borough do you live in?

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* 9. Which borough do you work in?

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

Yes

Mabadiliko CIC - Expression of Interest Form 2023/24

Question Title

* 1. Please tell us your full name.

Question Title

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

Question Title

* 3. Please tell us your email address.

Question Title

* 4. Please tell us your phone number

Question Title

* 5. Which service/ emotional support are you interested in?

Question Title

* 6. I am also interested in the following:

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* 7. Please tell us a little more about you area of interest (optional).

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* 8. Which borough do you live in?

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* 9. Which borough do you work in?

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* 10. Referral Organisation

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

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* 12. To prove you are human, please choose the images with palm trees.