S4C Registration Form

Support For Parents and Loved Ones

First Steps ED offer many forms of support for Parents, Carers, and loved ones of those struggling with their eating. Our 1:1 and group support services are all based on the Maudsley method, a family-based approach to treating Eating Disorders. Our "Skills For Carers" 4-week psychoeducational workshop provides knowledge and guidance to support your child or loved one in their battle with low self-esteem, disordered eating, or body image issues. The course runs for 90 minutes each week over Microsoft Teams.
Which area do you live in?*

HertfordshireDerbyshireNorth StaffordshireSouth StaffordshireWest Midlands (including Birmingham)LeicestershireLincolnshireOther
About your loved one....

We need to ask a few questions about the person you are supporting so that we can get you the right help.
Has the person you care for accessed any formal treatment for disordered eating (e.g. from CAMHS ED or an Adult Eating Disorder Service)

Yes, they are currently accessing treatmentYes, they have had treatment in the pastNo, but they have had an assessment and are waiting for treatmentNo, they have not had or do not need formal treatment at this pointUnsure
Tell us a bit about more who you care for.....*
Please include their age, relationship to you, and current difficulties.
Your Details

We need this information to ensure that we are providing accurate and good quality support to all our service users.
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
How did you hear about the workshop?*

Social MediaInternet search engineWord of mouthFirst Steps ED websiteFirst Steps ED NewsletterProfessional ReferralStudent Space (University Students)Other
Date of Birth*

DayMonthYear
Date
In Case of Emergency
GP practice name
Only to be used in case of an emergency
Name of emergency contact (Next of Kin)*

First NameLast Name
Phone Number of emergency contact

Area CodePhone Number
Phone Number of Emergency Contact*
Equality and Diversity Monitoring
What is your gender?*

FemaleMaleNon-binaryTransgenderPrefer not to sayOther
What is your religion/religious denomination?

ChristianityIslamSikhismJudaismHinduismBuddhismJanismTaoismNo religionPrefer not to sayOther
What is your sexual orientation?

Straight/HeterosexualBisexualGay/HomosexualPrefer not to sayOther
What is your nationality/ethnic origin?

ArabAsian / Asian British- IndianAsian / Asian British- PakistaniAsian / Asian British- BangladeshiAsian / Asian British- ChineseAsian / Asian British- Any other Asian backgroundBlack / African / Caribbean / Black British- AfricanBlack / African / Caribbean / Black British- CaribbeanBlack / African / Caribbean / Black British- Any other Black / African / Caribbean backgroundMixed / Multiple ethnic groups- White and Black CaribbeanMixed / Multiple ethnic groups- White and Black AfricanMixed / Multiple ethnic groups- White and AsianMixed / Multiple ethnic groups- Any other Mixed / Multiple ethnic backgroundWhite- English / Welsh / Scottish / Northern Irish / BritishWhite- IrishWhite- Gypsy or Irish TravellerWhite- Any other White backgroundAny other ethnic groupsPrefer not to sayUnsureOther
By submitting this workshop registration form, you consent to us contacting you directly and collecting and processing the information that you have provided on our systems in accordance with GDPR and provide assurance that your personal details are not shared with any third party. We use your contact details to provide you with the joining instructions for your selected workshops.
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Support For Parents and Loved Ones

About your loved one....

Your Details

In Case of Emergency

Equality and Diversity Monitoring