Aware NI - Living Life to The Full - Application Form

Home
About Us
Media
Contact Us

Information
How We Can Help You
Wellbeing Programmes
Fundraising
Investors in Mental Health Awards
Covid-19 Support

info@aware-ni.org

Donate to AWARE

Home
About Us
Media
Contact Us

Information
How We Can Help You
Wellbeing Programmes
Fundraising
Investors in Mental Health Awards
Covid-19 Support

Home
Wellbeing Programmes
Living Life to the Full
Living Life to The Full - Application Form

Description:

South Eastern Trust (Zoom) beginning Wed 10 Feb 6.30-8.30 pm (Ref:549)

Date:

Wednesday, 10 February 2021 18:30

Living Life to The Full - Application Form

1. Which of the following best describes you?(*)

a. I currently have good mental health and would like to learn how to maintain this

b. I am currently experiencing general low mood/stress/anxiety

c. I am currently experiencing mild to moderate depression

Invalid Input

I would like to feel happier and better equipped to deal with life's problems(*)

YesNo

Invalid Input

I want to make some changes in my life and I am prepared to try new things (*)

YesNo

Invalid Input

I plan to attend all sessions in order to gain maximum benefit from the programme(*)

YesNo

Invalid Input

I have basic reading skills e.g. I can read a tabloid newspaper (*)

YesNo

Invalid Input

I am happy to attend a group-based programme and participate in discussions with the facilitators and other group members(*)

YesNo

Invalid Input

Full Name(*)

Invalid Input

Date of Birth(*)

/ / Invalid Input

Address(*)

Invalid Input

Postcode(*)

Invalid Input

Telephone(*)

Invalid Input

Email(*)

Invalid Input

Please state below if you have any access requirements: (including help with reading and writing)?

Invalid Input

If you have been referred by your GP or mental health professional please insert their name and contact details:

Invalid Input

If self-referring, please give details of any other support you are receiving e.g. from family/friends or voluntary organisation:

Invalid Input

Have you any illness or disability for which you might need help accessing the programme? Please give details

Invalid Input

Is there any other information you feel is relevant to your application?

Invalid Input

I hereby apply for a place on the LLTTF programme and confirm that the information I have provided is accurate and complete.

If requested, I agree to provide information, which will assist in the overall evaluation of the programme.

I understand that any such information will be provided anonymously, will be treated in strictest confidence
and will not be used for any other purpose.

Signed

Invalid Input

AWARE is the depression charity for Northern Ireland and the only charity working exclusively for those with depression and bipolar disorder.

BELFAST OFFICE

40-44 Duncairn Gardens,
Belfast,
BT15 2GG

Tel: 028 9035 7820

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

DERRY/LONDONDERRY OFFICE

15 Queen St,
Derry,
BT48 7EQ

Tel: 028 7126 0602

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Login
Sitemap
Privacy

Website by Elm House Creative