Lamplight API response

Email address

Mobile phone

Phone number

By post

By email

By mobile

By text message

How would you like to receive information about SLT future events?* Please tick all that apply. You can change your preferences at any time regarding how you wish SLT to contact you by telephoning or emailing SLT.

Email (newsletter)

Post (flyer)

I do not want information about activities

More about you and your preferences

Preferred pronoun*

she / her / hers

he / him / his

they / them / theirs

ze / hir / hirs

No pronoun

No preference

Not sure / prefer not to say

Other (please use the text box in the next question)

If you selected 'Other' please use the free-text space below to express how you identify

Living situation*

If you selected 'Other' please describe your living situation below

If you selected 'Other' please describe your employment status below

Do you currently receive any support from the below public services?* (Please tick all that apply)

NHS mental health service

Social care / social worker

Community nursing

Drug & alcohol rehab service

Probation service

None of the above

Prefer not to say

Other (please use the text box in the next question)

If 'Other' selected please state public services below

Mobility*

If you selected 'Other' please describe your mobility below

Are there any particular activities or services that you would like SLT to provide?

Other than SLT, do you belong to a social network that meets regularly either in person or virtually?*

If you selected "yes" please provide the name(s) of other organisation(s) you engage with regularly

How did you hear about SLT?*

Word of mouth

Online eg Google

Flyer on a notice board

Flyer through post

Community Centre/Library

Healthcare professional / social worker / referral by social prescriber

Social Media

Other (please use the text box in the next question)

If 'Other' selected please describe how you heard about SLT below

Emergency Contact

Please use the boxes below to provide details of someone you would like us to contact in an emergency. This could be a family member, a friend, a support worker, or someone similar

Emergency Contact - Name*

Emergency Contact - Phone number*

Emergency Contact - Email (state 'na' if not known)*

Professional support

If you are being supported by an NHS or Council Care Coordinator or Key Worker, and this is different from your 'Emergency Contact', please use the boxes below to provide their details:

Care Coordinator/Key Worker - Name

Care Coordinator/Key Worker - Service/Team

Care Coordinator or Key Worker - Phone Number

Care Coordinator or Key Worker - Email

Please tick the box below if you are you completing this form because you have been referred by a professional body? Or if you are a professional body referring a person to SLT?

Is this a Professional Referral to SLT?

Equal opportunities monitoring

Date of Birth*

Ethnicity*

If you selected 'Other' please use the space below to best describe your ethnicity

Gender*

If you selected 'Prefer to self-describe' please use the space below to express how you identify in terms of gender

Sexual orientation*

Faith / Religion*

If you selected 'Other' please use the space below to best describe your faith / religion

Do you identify as having lived experience with mental health issues?*

Are your day-to-day activities significantly limited because of a physical or mental health condition or illness* (this could be anxiety or depression) which has lasted, or expected to last, at least 12 months?

*For the above question, consider conditions that always affect you and those that flare up from time to time. These may include, for example, sensory conditions, developmental conditions or learning impairments.

If you answered "yes" above, please select the type(s) of physical or mental health condition or illness. If you have more than one, please tick all boxes that apply.

Physical impairment

Autism spectrum

Mental Health condition

Long standing illness

Sensory impairment

Learning disability

Other developmental condition

Prefer not to say

Other

Additional information on your physical or mental health condition or illness.

Please use the box below to provide more detail on anything else that will help SLT better understand your needs

SLT are currently unable to provide one-to-one support at activities. If you need specific support or assistance, or would like to find out more, please contact SLT on info@slt.org.uk or 0207 713 9304 in advance

Thank you, we appreciate your time in completing this form

Participant Registration Form

Other information

More about you and your preferences

Emergency Contact

Professional support

Equal opportunities monitoring