Finding the Words: for young people with an eating problem or disorder, and young people who are struggling with body image (16-25)

Registration form

If you have any questions please don’t hesitate to contact us: david.rawlings@stroud.gov.uk or hollie.jones20@nhs.net

This form must be completed and received by Stroud District Council (Community Health & Wellbeing Team) before a young person can commence full participation in this project.

Stroud District Council (SDC) is working in partnership with:

Berkeley Vale Primary Care Network (BV PCN)
Severn Health Primary Care Network (BV PCN)
Jason Conway: a published author, poet and writer based in Gloucestershire

This course is open to young people (aged 16-25 years old) who are registered at any of the surgeries within the Stroud District.

We recognise the ability of competent young people to also provide consent. As such, this form should be signed by the young person and their parent or legal guardian if under 18.

Data Protection: SDC processes personal data in accordance with the General Data Protection Regulation 2016 and the Data Protection Act 2018. For information about how we process personal data, please refer to the Council’s Privacy Notices which can be found at: stroud.gov.uk/privacynotice

You can withdraw your consent by contacting:
david.rawlings@stroud.gov.uk

Question Title

* 1. Do you understand how to access information about our privacy policy?

Yes

SHARING YOUR INFORMATION:

We take your privacy seriously and will never sell your information to third parties.

We are required by law to share information with relevant authorities if we become concerned about someone’s safety.

Question Title

* 2. Do you understand how we share your information:

Yes

CONTACTING YOU:

Whilst working with SDC, BV PCN, SH PCN & Jason Conway we may need to contact you with information about the specific project you are involved in. We would like to use your email address in order to get messages to you.

Question Title

* 3. Tick here if you are happy to receive information by:

COMMUNICATIONS:

SDC, BV PCN, SH PCN & Jason Conway would like to stay in touch with you. The types of things we might send include: information about opportunities to be involved with our projects and relevant information about partner organisations. You can opt out of receiving information at any time.

Question Title

* 4. Tick here if you are happy to receive communications from us by:

Question Title

* 5. YOUNG PERSONS DETAILS:

The information below is required to be involved in the project.

Name

Address

Town

Postal code

Email Address

Phone number

Nickname

Pronouns

Date of Birth

Age

GP Surgery

Question Title

* 6. Please choose the statement that best describes the current situation:

Showing early signs of unhelpful thoughts and behaviours around eating or body image

Have seen a GP about these concerns

Seeing a counsellor eg, Teens In Crisis, Young Gloucestershire

Are on the waiting list for an NHS service eg, Brownhills / CAMHS

Receiving clinical treatment from an NHS service eg, Brownhills / CAMHS

Discharged from an NHS service or other formal support eg, Brownhills, CAMHS, counselling

Have an ongoing eating problem or struggling with body image but have not voiced these concerns to a health professional

Other (please specify)

Question Title

* 7. PARENT / GUARDIAN DETAILS:

A parent or guardian of a young person under 18 will need to enter their details below and complete the consent section.

Name

Relationship to young person

Address

Phone number

Email address

CONSENT FOR PROJECT INVOLVEMENT:

Consent is required before a young person can fully participate in this project run by SDC, SBV PCN, SH PCN & Jason Conway.

Question Title

* 8. Young Persons Declaration

I consent to taking part in this project run by SDC, BV PCN, SH PCN & Jason Conway. I understand that the staff responsible will take all reasonable care of me and other participants.

Young Person's Name

Date (DD/MM/YYYY)

Question Title

* 9. Parental Declaration (for young people under 18)

I confirm that I have parental responsibility for the above young person and consent to them taking part in this project run by SDC, SBV PCN, SH PCN & Jason Conway.

Parent / Guardian Name

Date (DD/MM/YYYY)

Question Title

* 10. Parental consent for online platforms

The named young person can access and use video platforms (e.g. Zoom) that require specific parental consent at the point of use, for the purposes of their involvement in this project.

Yes

READING & WRITING HABITS

Question Title

* 11. Have you done any writing in the last 3 months?

For example: diary, journalling, putting thoughts on paper, poetry, flash fiction

Never

Less than once a month

Once or twice a month

Once or twice a week

Every day or almost every day

Question Title

* 12. How often do you read?

For example: books, newspapers, magazines, websites, blogs

Never

Less than once a month

Once or twice a month

Once or twice a week

Every day or almost every day

Finding the Words: for young people with an eating problem or disorder, and young people who are struggling with body image (16-25)

Registration form

Question Title

* 1. Do you understand how to access information about our privacy policy?

Question Title

* 2. Do you understand how we share your information:

Question Title

* 3. Tick here if you are happy to receive information by:

Question Title

* 4. Tick here if you are happy to receive communications from us by:

Question Title

* 5. YOUNG PERSONS DETAILS: The information below is required to be involved in the project.

Question Title

* 6. Please choose the statement that best describes the current situation:

Question Title

* 7. PARENT / GUARDIAN DETAILS: A parent or guardian of a young person under 18 will need to enter their details below and complete the consent section.

Question Title

* 8. Young Persons Declaration I consent to taking part in this project run by SDC, BV PCN, SH PCN & Jason Conway. I understand that the staff responsible will take all reasonable care of me and other participants.

Question Title

* 9. Parental Declaration (for young people under 18)I confirm that I have parental responsibility for the above young person and consent to them taking part in this project run by SDC, SBV PCN, SH PCN & Jason Conway.

Question Title

* 10. Parental consent for online platformsThe named young person can access and use video platforms (e.g. Zoom) that require specific parental consent at the point of use, for the purposes of their involvement in this project.

Question Title

* 11. Have you done any writing in the last 3 months? For example: diary, journalling, putting thoughts on paper, poetry, flash fiction

Question Title

* 12. How often do you read? For example: books, newspapers, magazines, websites, blogs

* 5. YOUNG PERSONS DETAILS:

The information below is required to be involved in the project.

* 7. PARENT / GUARDIAN DETAILS:

A parent or guardian of a young person under 18 will need to enter their details below and complete the consent section.

* 8. Young Persons Declaration

I consent to taking part in this project run by SDC, BV PCN, SH PCN & Jason Conway. I understand that the staff responsible will take all reasonable care of me and other participants.

* 9. Parental Declaration (for young people under 18)

I confirm that I have parental responsibility for the above young person and consent to them taking part in this project run by SDC, SBV PCN, SH PCN & Jason Conway.

* 10. Parental consent for online platforms

The named young person can access and use video platforms (e.g. Zoom) that require specific parental consent at the point of use, for the purposes of their involvement in this project.

* 11. Have you done any writing in the last 3 months?

For example: diary, journalling, putting thoughts on paper, poetry, flash fiction

* 12. How often do you read?

For example: books, newspapers, magazines, websites, blogs