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Which option best describes you * Please Select... I am under the care of mental health services in Bolton I am under the care of mental health services in Central Manchester I am under the care of mental health services in North Manchester I am under the care of mental health services in Salford I am under the care of mental health services in South Manchester I am under the care of mental health services in Trafford I am under the care of mental health services in Wigan I am under the care of Child and Adolescent Mental Health Services (CAMHS) I use Primary Care Psychological Therapy Services (often referred to as IAPT) I use Specialist Community Psychological Therapy Services (e.g. Military Veterans Service, Eating Disorder Service, Perinatal Community Mental Health Team) I use Health and Justice Services I am a patient in Adult Forensic Services I am a patient in Rehabilitation Services I am a patient in the Mental Health and Deafness Unit (John Denmark Unit) I use Addiction Services I support someone with mental health/addiction difficulties as a friend or family member I am a professional who works in the voluntary sector I am a professional who works in the statutory sector I am a professional who works privately for myself/private organisation Student Other Background Information – Strictly Confidential (Monitoring Purposes Only)
Special Requirements Do you have any special requirements that you think we should be aware of e.g. special needs, large print course materials, disabled access, requirement for one to one support help to define long term goals?
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Do you consider yourself to have a physical or mental health condition or disability? Please Select... No Yes
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Which of the following best describes your ethnic background? * Please Select... Asian or Asian British – Bangladeshi Asian or Asian British – Pakistani Asian or Asian British – Indian Asian or Asian British – Any other Asian background Black or Black British – African Black or Black British – Caribbean Black or Black British – Any other Black background Mixed – White & Asian Mixed – White & Black African Mixed – White & Black Caribbean Mixed – Any other Mixed background White – British White – Irish White – Any other White background Other Ethnic Group – Chinese Other Ethnic Group – Any other Ethnic group I do not wish to disclose this
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