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Support details

Tell us a little about yourself, and who we should contact in case of emergencies.

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Are you a resident of Tower Hamlets?*

Yes

What is your connection to mental health in Tower Hamlets?

Service User

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Trainee/Student

Carer

Family Member

NHS Staff

Other Staff

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Do you consider yourself to be disabled?

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If yes, please state the type of health problem or disability that applies to you?

Physical Impairment

Sensory Impairment

Mental Health Condition

Learning Disability

Long standing illness or health condition

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Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least twelve months (include any problems related to old age)?

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What best describes your gender? (Please insert tick below)

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Self-describe your gender

Is your gender identity the same as the sex you were assigned at birth? (Please insert tick below)

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Which of the following describes your sex? (Please insert tick below)

Man

Woman

Intersex

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Self describe your sex

Which of the following describes your sexual orientation? (Please insert tick below)

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Gay Woman/Lesbian

Gay Man

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Self-describe your sexual orientation

Equality & identity

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Are you legally married or in a civil partnership? (Please insert tick below)

Yes

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Which best describes your current marital, civil partnership or cohabitation status (Please insert tick below)

Married

Single

In a registered Civil Partnership

Divorced

Widowed

Cohabitating with a partner

Separated, but still legally married

Separated, but still in a registered civil partnership

Formerly in a registered civil partnership which is now dissolved

Surviving partner from a registered civil partnership

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Are you a veteran? (Have you served time in any military armed force?)

Yes

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Are you currently pregnant or did you give birth in the last twelve months? (Please insert tick below)

Yes

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How would you describe your ethnic group? (Please insert tick below)

Bangladeshi

Pakistani

Indian

Other Asian Background

African

Caribbean

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Other Black Background

British

Irish

Traveller of Irish Heritage

Gypsy/Roma

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Vietnamese

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Any Other

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Which best describes your first language? (Please insert tick below)

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What is your religion or belief? (please insert tick below)

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Which best describes your employment status? (Please insert tick below)

Employed (Full Time)

Employed (Part Time)

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Self Employed (Part Time)

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Student (Part Time)

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