Pre interest Wellbeing Workshop Form

Wellbeing Workshop Pre-interest Form

Clayton Sure Start Centre, 101 North Rd, Clayton, Manchester M11 4NE
We want to try and get an idea of attendance numbers and background information for our Wellbeing Workshops

As such, we would be grateful if you would complete this pre-interest form as honestly and as fully as possible.
Name:*
Postcode:*
Telephone:*
Email
example@example.com

Do you currently claim benefits? (Please select which ones apply)*

	Benefit choices
UC - Universal Credit
JSA - Job Seekers Allowance
ESA - Employment & Support Allowance
DLA - Disability Living Allowance
PIP - Personal Independent Allowance
AA - Attendance Allowance
None
Prefer not to say

Below are a list of workshops and details of when they are taking place. Please select which ones you want to attend*

	Wellbeing workshop choices
1 - 5 Ways 2 Wellbeing - 17/09/25: 1pm to 3pm
2 - Break the habit - Smoking - 01/10/25: 1pm to 3pm
3 - Sleep - 15/10/25: 1pm to 3pm
4 - Healthy Eating -12/11/25: 1pm to 3pm
5 - Stress & Relaxation - 26/11/25: 1pm to 3pm
6 - Confidence in communication - 02/12/25: 1pm to 3pm
7 - Mindfulness - 10/12/25: 1pm to 3pm
8 - Physical Activity - 17/12/25: 12pm to 2pm

As part of our social media & marketing campaign regarding wellbeing workshops we may do the following:*

	Yes	No
I am happy in appearing in photos or video footage
I am happy in providing a video testimony at the end of a workshop
I am happy with being a case study if needed

Equal Opportunities Monitoring:

For us to analyse whether there are any patterns in the running of our workshops, we invite you to answer the following questions. You do not have to answer them if you do not wish.
Age:
Ethnicity/ Heritage:
BMS Wellbeing CIC - Understanding you

www.bmswellbeing.com, joelwhite@bmswellbeing.com, Mobile: (+44) 07853 629 771
Should be Empty:

	1 - None of the time	2 - Rarely	3 - Some of the time	4 - Often	5 - All of the time
I’ve been feeling optimisitc about the future
I’ve been feeling useful
I’ve been feeling relaxed
I’ve been dealing with problems well
I’ve been thinking clearly
I’ve been feeling close to other people
I’ve been able to make my mind up about things

	1 - None of the time	2 - Rarely	3 - Some of the time	4 - Often	5 - All of the time
I am content with my friendships and relationships
I have enough people i feel comfortable asking for help at any time
My relationships are as satisfying as i would want them to be

BMS Wellbeing CIC - Understanding you