Member type	Public Patient
Title	Organisation Mr Mrs Miss Ms Dr Professor Canon Reverend Capt Wing Commander Col Major Commodore Cllr Sister Master Lady Mayor Bishop Esq Inspector Lord Rt. Hon Sire Police Constable Sheriff Sheriff's Lady
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Preferred method of contact	Email Post
Ethnicity	Not stated White - English, Welsh, Scottish, Northern Irish, British White - Irish White - Gypsy or Irish Traveller White - Other Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Other Mixed Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Other Asian Black or Black British - African Black or Black British - Caribbean Black or Black British - Other Black Other Ethnic Group - Arab Other Ethnic Group - Any Other Ethnic Group
Sexual Orientation	Gay/Lesbian Heterosexual Bisexual Asexual Not Stated

Special Postal Requirements	Easy Read Large Print Audio tapes Braille Audio CD
Do you consider yourself to have a disability?	No Yes Do you consider yourself to have a disability or longterm health condition? Yes A physical disability A learning disability A mental health problem Any other special need (please list in the 'Notes' section) DO you consider yourself to have a dis/long term dis? No yes Yes No
How would you like to be involved?	Hero (Please see website for details) Supporter (Please see website for details) Superhero (Please see website for details) Would like to become a member of Leeds Community Healthcare Trust
Service preferences	Adult Services Exercise Touch and Movement Forensic Services Gender Identity Learning Disabilities Leeds Addiction Unit Liaison Psychiatry Older People's Services Perinatal Mental Health Personality Disorders Yorkshire Centre for Eating Disorders Self Harm Prevention Chronic Fatigue/ME Self Harm Prevention Chronice Fatigue/ME Carers Pharamacy Service Volunteering Work Exerience Healthy Living Service Positive Mental Health Promotion Anti Stigma Events Annual General Meeting Governors Elections Membership Diversity and Equality Human Resources and Recruitment Patient Safety Arts and Minds Network Fundraising Service User Network
How did you hear about the trust?	Leaflet in GP surgery Word of Mouth Other (Please Specify) Former member of staff

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Date of birth
Gender
Address
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Ethnicity
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How did you hear about the trust?

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