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* 1. Your Name

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* 2. Your Job Role

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* 3. Your City

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* 4. In your own words, describe your ethnicity/ ethnic heritage

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* 5. In your own words, describe your gender identity and your preferred pronouns

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* 6. Do you use the Wellbeing Hub for the North East and North Cumbria Integrated Care System?

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* 7. In your own words, describe the reason for your answer to the previous question

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* 8. Would you like to participate in an Advisory Group that will be consulted on the design of wellbeing resources for you and your colleagues who identify as Black and minoritised womxn?

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* 9. If you answered 'Yes' to participating in the Advisory Group, please provide your email address below.

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* 10. Select all of the days of the week and times you are available in September 2022 to participate in 3 Stakeholder Group Consultation Sessions.

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