TLSG Members Form

New Member Form

Please complete this form to register as a member of the Teesside Lupus Support Group. Your information will help us stay in touch and support you. Address: The Robert Atkinson Centre, Thorntree Road, Thornaby, TS17 8DL. Email Tlsgstockton2013@gmail.com
Important: This group is not just for lupus support; we are also a supportive community for women facing various challenges. Everyone is welcome!
Date

DayMonthYear
Date
1. Personal Details
Full Name*

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

Street Address

Street Address Line 2
CityCounty Post Code
2. Current State / General Well-being (Simple Mood Check)
Let us know how your currently feeling..

Excellent (I feel very well and positive)Good (I feel generally stable and cope well)Fair (I have some ups and downs/some daily struggles)Poor (I am finding things very difficult right now)
3. Mental Health & Well-being: Current Impact

Please select the statement that best describes the current impact of your mental health and well-being on your daily life:
My mental health does not currently impact my daily activities.My mental health has a mild impact on my daily activities.My mental health has a moderate impact on my daily activities.My mental health has a severe impact on my daily activities.Prefer not to say
4. Demographic Information: Age Range
Please select your current age range:

Under 1818 – 2526 – 3536 – 4950 – 6465+Prefer not to say
5. Ethnic Origin and Background
Please select your ethnicity
6. Professional Status
Please select your current employment status

1. Employed (Full-Time)2. Employed (Part-Time)3. Self-Employed4. Unemployed5. Student6. Retired7. Other (Specify if selected)
7. Equality Act Compliance and Support Needs
Do you consider yourself to have a disability, long-term illness, or health condition that affects your day-to-day life?

YesNo
8. Membership Needs and Diagnostic Profile
When were you diagnosed with Lupus or other Chronic Diseases ?

Within the last 12 months (Newly Diagnosed)1 – 5 years ago5 – 10 years agoOver 10 years agoStill undergoing diagnosis/investigation
What are you hoping to gain most from joining this support group?

Emotional Support and ValidationInformation on Management and TreatmentSocial Connection and FriendshipAdvice on Managing Flare-UpsGeneral Awareness and Advocacy
What are you hoping to gain most from joining this support group?

Emotional Support and ValidationInformation on Management and TreatmentSocial Connection and FriendshipAdvice on Managing Flare-UpsGeneral Awareness and Advocacy
9. Strengths and Personal Goals
What is one personal strength or quality you bring to the support group community?
What is a small goal you would like to achieve in the next month to support your own well-being?
10. Group Contribution and Volunteer Skills
Are you interested in volunteering some time or professional expertise to help the Teesside Lupus Support Group?

Yes, regularly (e.g., attending committee meetings, consistent tasks)Yes, occasionally (e.g., helping at specific events, one-off tasks)No, but thank you for asking
If you answered 'Yes' above, please check any areas where you may be able to offer help: (Select all that apply)

Social Media/Communication (Managing accounts, drafting posts)Event Organization (Helping plan logistics for meetings/outings)Fundraising (Ideas, organization, or participation in fundraising activities)Financial/Admin Support (Bookkeeping, paperwork, charity admin)Professional Advice (e.g., legal, HR, medical, marketing—where appropriate)Peer Support (Offering 1:1 or small group emotional support)Other
11. Activity and Communication Preferences
What is your preferred method for attending support meetings or events?

In-person meetings/events (Face-to-face in the Teesside area)Online meetings/Webinars (Via platforms like Zoom)A mix of both
Which topics or types of activities would you be most interested in the group covering? (Select your top 3)

Clinical Updates (Latest research, treatment news)Symptom Management Workshops (Fatigue, pain, brain fog)Guest Speakers (Rheumatologists, dietitians, specialists)Wellness Activities (Meditation, gentle exercise, crafts)Social Outings (Coffee meetups, non-health-related gatherings)Family/Carer Support (Sessions focused on loved ones)
12. Geographic Reach and Group Visibility
How did you primarily hear about the Teesside Lupus Support Group?

Hospital/GP Clinic (Referred by a healthcare professional)Online Search (Google, internet directory)Social Media (Facebook, Instagram)Word of Mouth (From a friend or another member)Another Lupus/Charity OrganizationOther
13. Consent and Group Policy Agreement
Participation: I confirm I understand that I participate in all group activities at my own risk and am responsible for managing my personal health conditions.*

Confirm
Confidentiality: I agree to keep all personal stories and information shared by other members within the group strictly confidential.*

Confirm
Data Use (GDPR): I consent to the [Group Name] storing the personal data provided for the purposes of managing my membership and communicating group activities.*

Confirm
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New Member Form

Important: This group is not just for lupus support; we are also a supportive community for women facing various challenges. Everyone is welcome!

1. Personal Details

2. Current State / General Well-being (Simple Mood Check)

3. Mental Health & Well-being: Current Impact

4. Demographic Information: Age Range

5. Ethnic Origin and Background

6. Professional Status

7. Equality Act Compliance and Support Needs

8. Membership Needs and Diagnostic Profile

9. Strengths and Personal Goals

10. Group Contribution and Volunteer Skills

11. Activity and Communication Preferences

12. Geographic Reach and Group Visibility

13. Consent and Group Policy Agreement