Main Contact

Preferred pronoun

I describe my gender in a different way

Title

First name

Middle name

Surname *

Postcode

Address *

Town/City *

County *

Postcode *

Country

Preferred contact method *

Emails will be sent to the address below

Letters will be sent to the address above

Best time to phone

Email address

Phone

Mobile

Taxi driver number

Your date of birth

Reasonable Adjustments
Reasonable adjustments are changes that we can make to our services so that people with disabilities, illnesses, or health conditions can access them more easily. Please tell us the best way to communicate and support you in the space below. If you need help completing this, call us on 01803 201201.

Tell us how we can help you best

Do you need a different type of help/support?

I agree to be contacted for surveys and/or consultations  

Yes

No

About You

Why we ask these questions
We want to make sure our services are fair and accessible to everyone. By collecting information about the people who use our services, we can:

Check that we are reaching people from different backgrounds.
Understand the needs of our community better.
Spot if any groups are under- or over-represented.

How your information is used

It helps us make sure everyone is treated fairly.
We do not use it to identify individuals.
Please answer as many questions as you feel comfortable with.

Your age

How old are you?

Ethnic Background

What is your ethnicity?

I use another term to describe my ethnicity

Any other White background

Any other mixed or multiple background

Any other Asian background

Any other Black, Black British or Caribbean background

Sex and Gender

What is your sex?

Male

Female

Is your gender identity the same as the sex that you were registered with at birth?

Yes

No

Please use this space to describe your gender identity as you wish

What is your Sexual Orientation?

What is your sexuality?

I describe my sexual orientation in another way

Disability
Do you have any physical or mental health conditions or illnesses lasting or expected to last 12 months or more?

Yes

No

Do any of your conditions or illnesses reduce your ability to carry out day-to-day activities?

Yes, a lot

Yes, a little

No

Hearing impairment

Visual impairment

Learning difficulty

Mobility issues

Mental health condition

Long standing illness or health condition

Social or communication impairment

Any other disability, impairment or medical condition

I describe my health condition or disability in a different way

Care experienced
Do you provide unpaid care for someone you know? If a family member, friend, or neighbour cannot manage without your help, you may be a carer.

Yes

No

At any point in your life, have you spent time under the care of a local authority?

Yes

No

Religion
What is your religion?

I have another religion/ belief

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