Mabadiliko CIC - Expression of Interest Form 2023/24

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1. Please tell us your full name. (Required.)

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

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3. Please tell us your email address. (Required.)

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4. Please tell us your phone number (Required.)

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5. Which service/ emotional support are you interested in? (Required.)

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: (Required.)

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). (Required.)

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8. Which borough do you live in? (Required.)

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9. Which borough do you work in? (Required.)

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10. Referral Organisation (Required.)

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 (Required.)

Yes

Mabadiliko CIC - Expression of Interest Form 2023/24

Question Title

* 1. Please tell us your full name. (Required.)

Question Title

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

Question Title

* 3. Please tell us your email address. (Required.)

Question Title

* 4. Please tell us your phone number (Required.)

Question Title

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

Question Title

* 6. I am also interested in the following: (Required.)

Question Title

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

Question Title

* 8. Which borough do you live in? (Required.)

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* 9. Which borough do you work in? (Required.)

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* 10. Referral Organisation (Required.)

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

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

1. Please tell us your full name. (Required.)

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

3. Please tell us your email address. (Required.)

4. Please tell us your phone number (Required.)

5. Which service/ emotional support are you interested in? (Required.)

6. I am also interested in the following: (Required.)

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

8. Which borough do you live in? (Required.)

9. Which borough do you work in? (Required.)

10. Referral Organisation (Required.)

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

12. To prove you are human, please choose the images with palm trees. (Required.)