Active Minds Sessions

1
Name* This field is required.
First Name
Last Name
2
Date of Birth * This field is required.DD/MM/YYYY
3
Address* This field is required.
Address Line 1
Street Address Line 2
City
County
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
How long have you been attending our sessions?* This field is required.
First time attending sessions
Up to 3 months
3-6 months
6 months - 1 year
1-2 years
2 years +
5
Any medical conditions? Please state all conditions below or put N/A if none
6
Gender* This field is required.
Please Select
Please Select
Male
Female
Non-binary
Other
Prefer not to say
7
Is the gender you identify with the same as you were assigned at birth? * This field is required.
Please Select
Please Select
Yes
No
Prefer not to say
8
Ethnicity* This field is required.
Please Select
Please Select
White English
White Northern Irish
White Scottish
White Welsh
White British
White Irish
Other White background
White and Black Caribbean
White and Black African
White and Asian
Other Mixed background
Indian
Pakistan
Bangladeshi
Chinese
Other Asian background
Black Caribbean
Black African
Other Black background
Arab
Gypsy/Roman/Traveller
Other Ethnic group
Prefer not to say
9
Faith* This field is required.
Please Select
Please Select
Not known
No religion
Christian
Buddhist
Hindu
Jewish Muslim
Sikh
Any other religion
Prefer not to say
10
Sexual orientation * This field is required.
Please Select
Please Select
Not known
Straight
Gay or Lesbian
Bisexual
Other
Prefer not to say
11
Email* This field is required.
example@example.com
12
Mobile Number
13
Emergency contact details* This field is required.
14
Are you in education, employment or training? * This field is required.
Please Select
Please Select
Yes
No
15
Have you been excluded from school or college or are you at risk of being excluded? * This field is required.
Please Select
Please Select
Yes
No
16
Are you a refugee or asylum seeker, or a newly arrived migrant? * This field is required.
Please Select
Please Select
Yes
No
17
Do you have a social worker?* This field is required.
Please Select
Please Select
Yes
No
18
Are you a young carer?* This field is required.
Please Select
Please Select
Yes
No
19
Are you, or were you, eligible for free school meals?* This field is required.
Please Select
Please Select
Yes
No
20
Are you, or have you been affected by or associated with gangs and/or exploitation?* This field is required.
Please Select
Please Select
Yes
No
21
Are you experiencing or have you been affected by domestic violence and abuse? * This field is required.
Please Select
Please Select
Yes
No
22
Are you experiencing homelessness? * This field is required.
Please Select
Please Select
Yes
No
23
Any questions/concerns* This field is required.
Should be Empty: