Evolving Mindset - Registration Form (21/22 ARCHIVE)

Evolving Mindset CIC Referral Page

Evolving Mindset are a non profit organisation based in Merseyside. We are a Community Interest Company, providing bespoke mental health workshops for individuals with mild to moderate common mental health difficulties and/or carers/family members. We are not a Clinical Mental Health Service - we still advise to seek advice from your GP or professional team if needed.

This form is to help us understand you better and how we can tailor our support to you. This form should take less than 5 minutes to complete. Any information you provide will be treated as sensitive and confidential and will not be shared without your permission.

Our wellbeing programme is delivered online via Zoom. We would like to reassure you that it is not necessary to have your camera and microphone on during the sessions. We want participants to feel as comfortable as possible and there is no requirement to actively engage with facilitators or other participants during the session.

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* 1. What is your name?

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* 2. What is your age

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 3. What Gender do you identify with?

Female

Male

Transgender

other

Prefer not to say

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* 4. What is your ethnicity?

White (English, Welsh, Scottish, Northern Irish or British
Irish Gypsy or Irish Traveller, Any other White background)

Mixed or Multiple ethnic groups (White and Black Caribbean, White and Black African, White and Asian, Any other Mixed or Multiple ethnic background)

Asian or Asian British (Indian, Pakistani, Bangladeshi, Chinese, Any other Asian background)

Black, African, Caribbean or Black British (African, Caribbean, Any other Black, African or Caribbean background)

Other ethnic group (Arab, Any other ethnic group)

prefer not to say

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* 5. Area of GP

Liverpool

Knowsley

Sefton

Wirral

St Helens

Halton

Other (please specify)

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* 6. Where did you hear about us?

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* 7. What area support are you hoping to receive by attending Evolving Mindset workshops?

Low mood or depression

Stress

Anxiety

Low confidence/Low Self esteem

Isolation/Loneliness

Education/Learn new skills

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* 8. Please leave your email address below and one of the Evolving Mindset Team will contact you as soon as possible. You will be sent zoom links for the workshops via the e-mail address provided.

Email Address

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* 9. I do/do not consent for Evolving Mindset CIC to contact me

I give consent for Evolving Mindset CIC to contact me

I do not give consent for Evolving Mindset CIC to contact me

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* 10. Are there any special requirements that Evolving Mindset may need to make prior to you attending our workshops?

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* 11. We all know that getting support can be tough, and one thing that makes it easier is confidentiality. At Evolving Mindset we’ll always handle your information confidentially. We ask that you maintain the confidentiality of others who come along to our groups too

I agree

I do not agree

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* 12. Do you understand how to use Zoom to access the sessions?

Yes