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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

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