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Page 1: Your details

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* 1. Name

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* 2. Address

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* 3. Postcode Please format with a space in between e.g. LS1 1AA - not: LS11AA

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* 4. Contact numbers

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* 5. Please tick if we can

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* 6. May we contact you via email?

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* 7. Date of birth

Date

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* 8. What are your pronouns? e.g. She/Her, He/Him, They/Them, Ze/Hir

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* 9. Emergency contact

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* 10. Do you have any physical access or health needs that we should be aware of? Please give details.

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* 11. Do you have any communication needs?

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* 12. How did you hear about our service?

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* 13. Please give details of any support services you are currently accessing.

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* 14. Your GP Practice (We use this for monitoring access to our service and will only contact your GP with your permission)

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