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* 1. Please tell us your full name.

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* 2. What is your email address?

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* 3. What is your phone number? 

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* 4. Do you live in the London Borough of Lewisham?

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* 5. What is the first part of your postcode e.g. SE6

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* 6. Which of the following genders do you identify with?

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* 7. Which age category best applies to you?

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* 8. Which ethnicity best applies to you?

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* 9. What is your sexual orientation?

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* 10. What is your faith?

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* 11. Which date would you like to attend?

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* 12. Do you have any of the following disabilities or conditions (please select all that apply)

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* 13. What is your referral route?

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* 14. How did you hear about us?

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* 15. Difficulty with Intimacy regularly impacts my life in a negative way.

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* 16. I am able to recognise signs and symptoms when I find intimacy difficult. 

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* 17. I am able to manage the symptoms when I find intimacy difficult.

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* 18. I know where to access support when I need help with intimacy.

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* 19. What are you hoping to achieve from taking part in the Intimacy workshop (please select all that apply)

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* 20. In your own words, please tell us what you hope to achieve by joining the Intimacy workshop.

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* 21. I would like to receive email updates from Mabadiliko CIC

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