Realities & Ripple Effects
Welcome! This is a free 6-week trauma-informed group programme by Akima Charity taking place in Brent, Stonebridge. We provide a safe, supportive environment for young people. After you submit this form, Akima will follow up with you. Please answer the questions below—there are no right or wrong answers.
Young Person Details
Full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Please Select
Female
Male
Non-binary
Prefer not to say
Other
Area or postcode
*
Phone number
*
Please enter a valid phone number.
Format: 07000000000.
Email address
*
example@example.com
Religion
*
Christian
Muslim
Hindu
Jewish
Sikh
Buddhist
None
Prefer not to say
Other
Emergency Contact
Emergency contact name
*
Relationship to you
*
Emergency contact number
*
Please enter a valid phone number.
Format: (000) 000-0000.
About You
Disability
*
Physical disability
Mental health need
Learning difficulties
Other: Please describe
No
Prefer not to say
Why would you like to join this programme?
What do you hope to get out of the programme?
Any support needs, wellbeing needs, or important information we should know?
Dietary requirements
*
No requirements
Vegetarian
Vegan
Halal
Kosher
Gluten-free
Other
Parent/Carer Details
If under 18 years old
Parent/Carer full name
First Name
Last Name
Parent/Carer email address
example@example.com
Parent/Carer phone number
Please enter a valid phone number.
Format: 07000000000.
Availability
Who is filling out the form
*
Self referral
Parent/Carer
Professional
Other
Can you commit to attending weekly sessions for 6 weeks?
*
Yes
No
Unsure
Are there any dates you know you will be unavailable during the 6 weeks?
How did you hear about R&RE
*
School/college
Friend/family
Community group
Social media
Akima Charity
Other
Consent to Contact
I agree for Akima Charity to contact me about the Realities & Ripple Effects programme.
*
I agree
Thank you for your interest! Akima Charity will be in touch soon. If you have any questions, contact us at contact@akimacharity.org or 0208 079 2198.
Submit
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