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Which hub would you like to attend?
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Stockport Hub
Bolton Hub
Gorton
Title
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Mrs.
Ms.
Mr.
Dr.
First Name
Middle Name
Last Name
Client Details
Gender
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Female
Male
Prefer not to say
Date of Birth
Individual Details
Ethnicity
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Asian British
Asian Bangladeshi
Asian Indian
Asian Pakistani
Any other Asian background, please state
Black British
Black African
Black Caribbean
Any other Black background, please state
Arab
Chinese
Dual Heritage - Asian and White
Dual Heritage - Black African and White
Dual Heritage - Black Caribbean and White
Dual Heritage - Chinese and White
Any other Mixed background
White British
White Irish
White - Other European
Gypsy or Irish traveller
Any other White background, please state
Any other ethnic group, please give detail
Not known
Prefer not to say
Ethnicity - other
Religion
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Buddhism
Christian
Hinduism
Jewish
Islam
Sikhism
Judaism
No Religion
Other Religion
Prefer not to say
Nationality
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Angola
Antigua and Barbuda
Australian
Bahamas
Barbados
Belize
Benin
Botswana
British
Burkina Faso
Burundi
Cameroon
Cape Verde Cabo Verde
Central African Republic
Chad
Comoros
Cuba
Democratic Republic of the Congo
Djibouti
Dominica
Dominican Republic
Equatorial Guinea
Eritrea
Eswatini
Ethiopia
Gabon
Gambia
German
Ghanaian
Greek
Grenada
Guinea
Guinea-Bissau
Guyana
Haiti
Indian
Irish
Italian
Ivory Coast Côte d'Ivoire
Jamaican
Kenya
Lesotho
Liberian
Madagascar
Malawi
Malaysian
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigerian
Pakistani
Phillipine
Polish
Portuguese
Republic of the Congo
Romanian
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Senegal
Seychelles
Sierra Leone
Somalia
South African
South Sudan
Spanish
Sudan
Suriname
São Tomé and Príncipe
Tanzania
Togo
Trinidad and Tobago
Uganda
Zambia
Zimbabwe
Zimbabwean
Sexual Orientation
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Heterosexual/Straight
Gay
Lesbian
Bisexual
Prefer not to say
Contact Details
Home Address Line 1
Home Address Line 2
City
Postcode
District
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Bolton
Bury
Manchester
Oldham
Rochdale
Salford
Stockport
Tameside
Trafford
Wigan
Other
Email
Telephone Number
Permission for voicemails to be left on your telephone
Yes
No
Do you use a mobile phone?
Yes
No
Mobile Number
Permission for voicemails to be left on Mobile
Yes
No
Do you give permission to receive text message reminders prior to you attending workshops?
Yes
No
First Language
When is the best time to contact you?
Do you consider yourself disabled?
Yes
No
If Yes please specify
If, yes please indicate the nature of your impairment
Do you have any allergies?
Yes
No
Allergies (Please state)
Do you have any conditions that affect your mobility?
Yes
No
Mobility (Please state)
Do you have any additional needs?
Hearing
Sight
Dyslexia
other (please state)
Please state
Any additional needs
Do you have any external support?
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Family/Friends
Carer
Social Worker
Other
External Support (Please state)
Referral Details
Who is making the referrals?
Organisation
Individual (family or friend)
Self-referral
How did you hear about CAHN?
Website
Radio
Organisation
Referrer Name
If other, how did you hear about CAHN
Referral Contact Number
Referrer Email
Referrer Organisation (Optional)
Common life problems
Parental problems
Relationship
Lifestyle problems
Drinking
Weight
Smoking
Stress
Other
Common mental health problems
Anxiety and panic attacks
Depression
Generalised anxiety disorder
Panic disorder
Suicidal Ideation
Hoarding
Loneliness
Menopausal
Self esteem
Self-harm
Trauma
Attention Deficit/hyperactivity Disorder (ADHD)
Other
Case Start Date
Emergency Contact Details
Emergency Contact Name
Emergency Contact Telephone day
Emergency Contact Mobile
Emergency Contact Email
Case Subject
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