Creative Health

Creative Health

For people who live and/or work in the Borough of Lambeth, who is LGBTQIA+ and are smokers seeking to quit and/or explore alternatives to smoking. Form to be completed by the person attending or referrer. Please complete where possible ALL sections of the form. The form is confidential.
Name*

First NameLast Name
Email*
example@example.com
Date of birth*

MonthDayYear
Date
Why do you want to attend?*

I'm currently trying to quit smokingI want to quit smoking but don't know where to startI'm not sure about quitting but I want to learn more about my optionsI don't want to quit but still want to learn more about my optionsI'm curious about Creative Health and smoking in LGBTQ+ communitiesOther
Address*

Address line 1

Address Line 2

CityBorough

Postcode
Phone number*
Contact permissions*

Allow EmailOK to contact by phoneFine with both contact methods
Do you consider yourself a member of the LGBTQIA+ Community?*

YesNo
Please confirm which sessions you would like to attend at Art4Space (SW4 6QU)*

Sat 11th October 10 am - 1 pm in Main studioWed 15th October 3-6 pm in Main studio
Emergency contact*

Name of emergency contactRelation to you
*

Emergency contact's phone numberEmergency contact's email
How would you define your gender?*
Ethnicity*

ArabAsian/Asian British: BangladeshiAsian/Asian British: ChineseAsian/Asian British: IndianAsian/Asian British: OtherAsian/Asian British: PakistaniBlack/Black British British: AfricanBlack/Black British British: CaribbeanBlack/Black British British: OtherMixed: OtherMixed: White and AsianMixed: White and Black CaribbeanOther Ethnic GroupWhite: BritishWhite: IrishWhite: OtherPrefer not to say
Referrers 's details (put N/A if not relevant)*

Referrers's NameReferrer's job title
*

Referrer's phoneReferrer's email
Any allergies we need to be aware of?*
Do you have any access considerations/anything additional you'd like us to know?*
Something that will make it easier for you to access the programme?
How did you hear about Creative Health /Art4Space?*

Social mediaFlyerFrom friend/familyFrom service/organisationOther
Do you give us consent to take photos?*

Evidence for funding applicationsFor Social Media & marketing purpose
Should be Empty: