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1. Personal Information
Title
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Mr
Mrs
Miss
Ms
Dr
Professor
Canon
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Wing Commander
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Col
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Cllr
Sister
Master
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Reverend Dr
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First name *
Last name *
Date of birth *
DD
MM
YYYY
Gender
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Other
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Address *
Town or City
County
Postcode *
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Home telephone
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Email *
Twitter
Follow @cwpnhs for latest news
Preferred method of contact
Email
Post
Telephone
SMS
Ethnic Origin
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
I do not wish to disclose
Sexual Orientation
Not Stated
Bisexual
Gay Man
Gay Woman / Lesbian
Heterosexual
Other
Prefer Not to Say
2. Additional Information
Disabilities
No
Yes
Prefer not to say
A learning disability (please specify)
A mental health problem (please specify)
A physical disability (please specify)
A sensory disability (please specify)
Communications Disability (please specify)
Any other special need (please specify)
How would you like to be involved?
Just updates and information only
Volunteering (work alongside staff to support people in services)
Lived Experience Advisor (help make improvements with staff using your experience of services)*
Becoming a Governor
Other
Which Services are you interested in?
Mental Health Services for Adults
Mental Health Services for Young People
Learning Disability Services
Physical Health Community Services
Other (If you have a particular interest, please state)
How are you connected with the Trust?
I have used services in the last 2 years
I care for someone who has used services in the last 2 years
I am a member of the public
I used to work at CWP
Other (please state)
How did you hear about the trust?
From a Governor
From a GP
A Friend or Member of the Family
Leaflet or poster
Local Newspaper or Radio
Member of Staff
Public Event
Online (Website/Twitter)
Other (please state)
3. Review
Last Used Services
Title
First name
Last name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
Twitter
Ethnic Origin
Sexual Orientation
Preferred method of contact
Disabilities
How would you like to be involved?
Which Services are you interested in?
How are you connected with the Trust?
How did you hear about the trust?
4. Finish
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