Emotional Support Group Registration - For Survivors of Domestic Violence and Abuse Survey

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* 3. Which phone number can the group facilitator contact you on? (Preferably a mobile phone number)

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* 4. Do you live or work the borough of Lewisham?

Yes

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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?

Male

Female

Trans-gender

Non-Binary

I'd prefer not to say

Other (please specify if you wish)

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* 7. Which age category best applies to you?

18-25

26-35

36-45

46-55

56-65

66-75

76-85

86+

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* 8. Which ethnicity best applies to you?

Black Caribbean

Black African

Other Black background incl Black British

White and Black Caribbean

White and Black African

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* 9. What is your sexual orientation?

Heterosexual

Gay

Bisexual

Lesbian

Asexual

Prefer not to say

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* 10. What is your faith?

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

Other (non-organised religion, Pagan, other religions)

No Religion (atheist, agnostic, no religion)

Prefer not to say

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* 11. What date would you like to attend?

16th March 2023 - 6pm to 8pm

6th May 2023 - 11am to 1pm

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

No Disability

Physical/Mobility Impairment

Visual / Hearing Impairment

Learning Difficulty

Long Term Condition / Illness

Mental Health Condition

Memory impairment

Registered Disabled

Prefer not to say

Other (incl. Depression, Anxiety, Diabetes)

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* 13. What is your referral route?

Self-Referral

IAPT Referral

BLG Mind referral

GP Referral

Mabadiliko CIC Referral

Referral from another Black-led Community/ Voluntary Group

Other (please specify)

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* 14. How did you hear about us?

Mabadiliko CIC

Word of mouth

Blue Print For All

South Lewisham PPG

Lewisham BME Network

Lewisham Local

Other (please specify)

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* 15. My emotional and mental wellbeing regularly impacts my life in a negative way.

1 - Strongly Agree

2 - Agree

3 - Disagree

4 - Strongly Disagree

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* 16. I am able to recognise signs and symptoms of poor emotional and mental wellbeing.

1 - Strongly Agree

2 - Agree

3 - Disagree

4 - Strongly Disagree

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* 17. I am able to manage the symptoms of poor emotional poor emotional and mental wellbeing.

1 - Strongly Agree

2 - Agree

3 - Disagree

4 - Strongly Disagree

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* 18. I understand where to access support when I need help with my emotional and mental wellbeing.

1 - Strongly Agree

2 - Agree

3 - Disagree

4 - Strongly Disagree

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* 19. Are you currently experiencing domestic abuse?

Yes

I'd prefer not to say

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* 20. I feel confident talking about my experience of domestic violence and abuse.

1 - Strongly Agree

2 - Agree

3 - Disagree

4 - Strongly Disagree

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* 21. I understand the impact of domestic violence and abuse on relationships.

1 - Strongly Agree

2 - Agree

3 - Disagree

4 - Strongly Disagree

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* 22. I understand the impact of domestic violence and abuse on myself (and any children) as survivors.

1 - Strongly Agree

2 - Agree

3 - Disagree

4 - Strongly Disagree

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* 23. I experience feelings of shame, guilt or self-blame as a result of domestic violence and abuse.

1 - Strongly Agree

2 - Agree

3 - Disagree

4 - Strongly Disagree

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* 24. What are you hoping to achieve from taking part in the Emotional Support Group (please select all that apply)

Routine /Structure to life

Reduce social isolation

Learn new skills

Improve quality of life

Social activity

Meet new people

Support/Engaged in the Community

Moving into paid employment

Other / No information given

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* 25. In your own words, please tell us what you hope to achieve by joining the Emotional Support Group for survivors of domestic violence and abuse.

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

Yes

Emotional Support Group Registration - For Survivors of Domestic Violence and Abuse

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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. Which phone number can the group facilitator contact you on? (Preferably a mobile phone number)

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* 4. Do you live or work the 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. What 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. My emotional and mental wellbeing regularly impacts my life in a negative way.

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* 16. I am able to recognise signs and symptoms of poor emotional and mental wellbeing.

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* 17. I am able to manage the symptoms of poor emotional poor emotional and mental wellbeing.

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* 18. I understand where to access support when I need help with my emotional and mental wellbeing.

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* 19. Are you currently experiencing domestic abuse?

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* 20. I feel confident talking about my experience of domestic violence and abuse.

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* 21. I understand the impact of domestic violence and abuse on relationships.

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* 22. I understand the impact of domestic violence and abuse on myself (and any children) as survivors.

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* 23. I experience feelings of shame, guilt or self-blame as a result of domestic violence and abuse.

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* 24. What are you hoping to achieve from taking part in the Emotional Support Group (please select all that apply)

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* 25. In your own words, please tell us what you hope to achieve by joining the Emotional Support Group for survivors of domestic violence and abuse.

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