Sign-Up Form 1 Information Checklist 2 Your Details 3 About You If there is any immediate or significant risk to yourself or others, please do not continue with this form and contact 111 or 999 immediately. I confirm there is no immediate or significant risk to myself or others. * If you are dependant on drugs or alcohol, please contact Inclusion (www.inclusioniow.org) or Equilibrium Project (www.equilibriumproject.co.uk) I am not dependantly using drugs or alcohol. * I am over 16. * I understand that Isorropia Foundation is a group workshop–based organisation and I’m happy to continue. * I agree to the collection and storage of the information I provide in this form by Isorropia Foundation, and I consent to the processing of my personal data. * Next First Name* Last Name* Have you had any previous surnames?* Yes No Please enter any previous surnames Date of Birth* NHS Number (if known) Gender* -- Select Option -- MaleFemaleNon-binaryOtherPrefer not to say Pronouns* -- Select Option -- She/HerHe/HimThey/Them Ethnicity* -- Select Option -- White - BritishWhite - IrishWhite - Any other White backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - Any other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - Any other Asian backgroundBlack or Black British - CaribbeanBlack or Black British - AfricanBlack or Black British - Any other Black backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - Any other ethnic groupNot known Phone Number* Email Address House Number and Street Name* Town/City* Postcode* GP Surgery* Emergency Contact Name* Emergency Contact Phone Number* Prev Next Where did you hear about Isorropia Foundation?* -- Select Option -- Access 2 InterventionCitizens AdviceCommunity Mental Health TeamFriends or FamilyGP SurgeryHome Treatment TeamHospitalHousing AssociationInclusion IOWJob CentreNHS Talking TherapiesParagonPolicePrevious MemberProbation ServiceRecovery ServiceSchool or CollegeSocial MediaTaster SessionWebsiteYouth TrustOther What is your living situation?* -- Select Option -- Owner OccupierTenant - Local AuthorityTenant - private landlordLiving with familyLiving with friendsUniversity or College accommodationMobile accommodationCare home without nursingCare home with nursingSpecialist HousingRough sleeperSquattingSofa surfingStaying with friends/family as a short-term guestBed and breakfast to prevent/relieve homelessnessSleeping in a night shelterHostel to prevent/relieve homelessnessTemporary housing to prevent/relieve homelessnessAdmitted patient settingsCriminal justice settingsOther (not listed) Are you at risk of becoming homeless?* For support around homelessness, contact Two Saints on 01983 520168 or visit www.twosaints.org.uk Yes No Employment Status* -- Select Option -- EmployedUnemployed - seeking workStudent - not working or seeking workLong-term sick or disabled (on benefits)Homemaker - not working or seeking workNot working - not on benefits or seeking workUnpaid voluntary work onlyRetired Have you been a member of Isorropia before? * No, I have never been a member of Isorropia Yes, I was a member within the last 6 months Yes, I was a member 7-12 months ago Yes, I was a member more than 12 months ago Have you ever experienced suicidal thoughts, or thoughts of harming yourself?* Yes No Have you ever self-harmed or made a suicide attempt?* Yes No What are your main wellbeing issues that you would like to address? Select all that apply. Addiction Anger or Frustration Anxiety Bereavement Emotional Instability Life Direction Loneliness Loss Low Mood Neurodiversity Relationship with food Relationships Self-Esteem, Confidence, Self-Worth Sleep Other Please give a brief description of the wellbeing issues that you would like to address: Are you receiving support from any other mental health services?* Yes No Please select Access to Intervention (A2i) CMHT Home Treatment Team NHS Talking Therapies Inclusion Youth Trust Psych Liason Paragon Mental Health Nurse Lighthouse Service Other Other services: Are you aware of any reason why you may pose a risk to vulnerable children, vulnerable adults, or others in a group setting?* Yes No Do you have any health, accessibility, care or support needs, or other barriers that may affect your ability to attend?* Yes No 12 + 2 = Submit
