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Client Enrolment Form
Section 1: About You
Title:
*
Mr
Mrs
Ms
Miss
Other
Other
First Name
*
Last Name
*
Phone Number
*
Email Address
*
Street Address
*
Address Line 2
City
*
County
*
Post Code
*
Age range
*
16-18
19–24
25–29
30–34
35–39
40–44
45–49
50–54
55–59
60–64
65 or over
Prefer not to say
Ethnicity
*
White British
White Irish
White Other
Chinese
Mixed White & Asian
Mixed White & Black Caribbean
Mixed White & Black African
Black or Black British-Caribbean
Black or Black British-African
Black or Black British-Other
Asian or Asian British-Pakistani
Asian or Asian British-Bangladeshi
Asian or Asian British-Indian
Asian or Asian British-Other
Other
Other
Gender
*
Male
Female
Transgender
Other
Prefer not to say
Do you consider yourself to have a disability?
*
Yes
No
Prefer not to say
What is the nature of your disability?
*
Long-term support needs
Physical disability
Learning disability
Mental health
Sensory support
Memory and cognition
Other
Additional information - please select all that apply
🛈
English as a second language
Neurodiversity issues
Health issues
Hearing issues
Recently made redundant
Live in a rural area
Carer responsibilities
Ex-offender
Drug/ Alcohol dependency
Returning to the labour market
Risk of redundancy
Low/ no qualifications
Long term unemployed
Economically inactive
In receipt of benefits
Single parent
Care leaver
Children in care
Dyslexic
Refugee
Homeless