Welcome to our survey

* Please complete both pages of this registration. Registration is incomplete until you click 'submit' *

By completing this form you agree to be contacted via email by the National Academy for Social Prescribing (“NASP”) and the Midlands Thriving Communities Partnership in relation to social prescribing and related Learning Together opportunities and are allowing us to share your data with NASP, its partners and affiliates. Privacy statement.

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* 1. Date of first contact with Midlands Regional Lead

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Personal details
Note - If you are filling this survey in on behalf of the person applying, please also state your name in brackets next to theirs.

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* 2. Name of person applying

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* 3. Email address

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* 4. Contact number (optional)

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* 5. Name of organisation

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* 6. Organisation postcode

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* 7. How did you hear about us?

Regional information
For more information on ICS regions and where your organisation falls please follow this link.

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* 8. What part of the region is your organisation based in? (tick all that apply)

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* 9. How would you describe the predominant geographical spread of your organisation?

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* 10. What communities does your organisation support? (tick all that apply)

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* 11. Please rank what you offer with 1 being the provision you provide the most

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* 12. Other provisions not listed (please state where you would place them in your ranking)

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* 13. How would you describe your organisation?

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