Help us to help you through Covid-19

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* 1. What is your name?

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* 2. What is your email address?

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* 3. What is your contact number?

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* 4. Would you like to be added to the Headway Teesside Mailing List? If so, what is your preferred method of communication?

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* 5. Using the sliding scale below, how would you rate how you are coping and managing day to day? (1 being not coping at all, 10 being coping as well as usual).

1 How are you coping? 10
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i We adjusted the number you entered based on the slider’s scale.

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* 6. What are the main issues affecting you at the moment?

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* 7. How often would you like to be in contact with Headway Teesside during this time?

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* 8. Headway Teesside have currently moved the monthly drop-ins to fortnightly virtual drop-ins via Zoom. Have you ever used Zoom?

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* 9. Our virtual drop-ins usually take place on the second Wednesday of each month at 1pm, and the fourth Wednesday of each month at 11am. If you could suggest a day and time that would suit you better, what would you suggest?

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* 10. Is there anything else we can do to help you at the moment?

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