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* 1. Are you a professional working with... (please tick all that apply)

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* 2. Are you... (please tick all that apply)

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* 3. Is there any client group within our scope (reducing risk of social isolation) which you feel would benefit from an activity group which is not currently provided in their area, or paused due to pandemic? (Please specify)

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* 4. Is there a geographical area you feel would particularly benefit from the development of this type of provison? (Please specify)

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* 5. Is there any other input you would like to give, for us to consider when arranging our groups?

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* 6. If you would like us to contact you in order to discuss further, or if you would like us to be aware of your service (some groups may be referral only), please leave whatever details you would like us to have here.  Please feel free to leave any or all boxes blank.

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