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LUV’ing you first – Support Group (Self Referral)
LUV’ing you first – Support Group (Self Referral)
Step
1
of
3
33%
YOUR DETAILS
Your Name
Your Age barrier
Under 18
18 - 24
25 - 30
31 - 40
41 - 50
51 - 60
60 +
Prefer not to say
Postcode
Contact number
Your Email
Reason for referral
Any additional support needs
i.e. childcare restrictions, health issues, dietary requirements/allergies, learning difficulties etc.
Would you like to be part of our Whatsapp group
Yes
No
The Whats App group will be other ladies on your course
SELF ESTEEM SCALE
I feel that I am a person of worth, at least on an equal plane with others.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel that I have a number of good qualities.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
All in all, I am inclined to feel that I am a failure.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I am able to do things as well as most other people.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel I do not have much to be proud of.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I take a positive attitude toward myself.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
On the whole, I am satisfied with myself.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I wish I could have more respect for myself.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I certainly feel useless at times.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
At times I think I am no good at all.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
Participant consent : I agree to my contact details being stored, accessed and used by LUV CIC and it’s subcontractors.
I agree
I do not agree
Preferred delivery method
*
Online
Face to face
Participant agreement: I agree to attend each session, at least 5 minutes before the start and contact LUV CIC if unable to attend. I also agree to fully participate in the sessions, without judgement and maintaining confidentially of the group
I agree
I do not agree
I have read and abide to the privacy policy stated in the footer
*
I have read this policy
Δ
CLOSE
LUV’ing you first – Support Group (Refer Someone Else)
LUV’ing you first – Support Group (Refer Someone Else)
Step
1
of
3
33%
YOUR DETAILS
Participant Name
Participant Age barrier
Under 18
18 - 24
25 - 30
31 - 40
41 - 50
51 - 60
60 +
Prefer not to say
Participant Postcode
Participant Contact number
Participant Email
Reason for referral
Any additional support needs
i.e. childcare restrictions, health issues, dietary requirements/allergies, learning difficulties etc.
Referrer Name
Referring Organisation
Referrer Contact Number
Referrer Email address
Preferred delivery method for the participant
*
Online
Face to face
The person I am referring abides to the privacy policy stated in the footer and they are aware of the referral and agrees to any contact
*
The referral has read this policy
Δ
CLOSE
LUV’ing you first – 6 Week (Self Referral)
LUV’ing you first – 6 Week (Self Referral)
Step
1
of
3
33%
YOUR DETAILS
Your Name
Your Age barrier
Under 18
18 - 24
25 - 30
31 - 40
41 - 50
51 - 60
60 +
Prefer not to say
Postcode
Contact number
Your Email
Reason for referral
Any additional support needs
i.e. childcare restrictions, health issues, dietary requirements/allergies, learning difficulties etc.
Would you like to be part of our Whatsapp group
Yes
No
The Whats App group will be other ladies on your course
SELF ESTEEM SCALE
I feel that I am a person of worth, at least on an equal plane with others.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel that I have a number of good qualities.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
All in all, I am inclined to feel that I am a failure.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I am able to do things as well as most other people.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel I do not have much to be proud of.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I take a positive attitude toward myself.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
On the whole, I am satisfied with myself.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I wish I could have more respect for myself.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
I certainly feel useless at times.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
At times I think I am no good at all.
*
Strongly Agree
Agree
Disagree
Strongly Disagree
Participant consent : I agree to my contact details being stored, accessed and used by LUV CIC and it’s subcontractors.
I agree
I do not agree
Preferred delivery method
*
Online
Face to face
Participant agreement: I agree to attend each session, at least 5 minutes before the start and contact LUV CIC if unable to attend. I also agree to fully participate in the sessions, without judgement and maintaining confidentially of the group
I agree
I do not agree
I have read and abide to the privacy policy stated in the footer
*
I have read this policy
Δ
CLOSE
LUV’ing you first – 6 Week (Refer Someone Else)
LUV’ing you first – 6 Week (Refer Someone Else)
Step
1
of
3
33%
YOUR DETAILS
Participant Name
Participant Age barrier
Under 18
18 - 24
25 - 30
31 - 40
41 - 50
51 - 60
60 +
Prefer not to say
Participant Postcode
Participant Contact number
Participant Email
Reason for referral
Any additional support needs
i.e. childcare restrictions, health issues, dietary requirements/allergies, learning difficulties etc.
Referrer Name
Referring Organisation
Referrer Contact Number
Referrer Email address
Preferred delivery method for the participant
*
Online
Face to face
The person I am referring abides to the privacy policy stated in the footer and they are aware of the referral and agrees to any contact
*
The referral has read this policy
Δ
CLOSE
