Referrals LUV'ing You First Program Referrals Self-Referral Step 1 of 3 33% YOUR DETAILSYour NameYour Age barrierUnder 1818 – 2425 – 3031 – 4041 – 5051 – 6060 +Prefer not to sayPostcodeContact numberYour Email Reason for referralAny additional support needsi.e. childcare restrictions, health issues, dietary requirements/allergies, learning difficulties etc.Would you like to be part of our Whatsapp groupYesNoThe Whats App group will be other ladies on your course SELF ESTEEM SCALEI feel that I am a person of worth, at least on an equal plane with others.*Strongly AgreeAgreeDisagreeStrongly DisagreeI feel that I have a number of good qualities.*Strongly AgreeAgreeDisagreeStrongly DisagreeAll in all, I am inclined to feel that I am a failure.*Strongly AgreeAgreeDisagreeStrongly DisagreeI am able to do things as well as most other people.*Strongly AgreeAgreeDisagreeStrongly DisagreeI feel I do not have much to be proud of.*Strongly AgreeAgreeDisagreeStrongly DisagreeI take a positive attitude toward myself.*Strongly AgreeAgreeDisagreeStrongly DisagreeOn the whole, I am satisfied with myself.*Strongly AgreeAgreeDisagreeStrongly DisagreeI wish I could have more respect for myself.*Strongly AgreeAgreeDisagreeStrongly DisagreeI certainly feel useless at times.*Strongly AgreeAgreeDisagreeStrongly DisagreeAt times I think I am no good at all.*Strongly AgreeAgreeDisagreeStrongly Disagree Participant consent : I agree to my contact details being stored, accessed and used by LUV CIC and it’s subcontractors.I agreeI do not agreePreferred delivery method*OnlineFace to faceParticipant 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 groupI agreeI do not agreeI have read and abide to the privacy policy stated in the footer* I have read this policy Δ Refer Someone Else Step 1 of 3 33% YOUR DETAILSParticipant NameParticipant Age barrierUnder 1818 – 2425 – 3031 – 4041 – 5051 – 6060 +Prefer not to sayParticipant PostcodeParticipant Contact numberParticipant Email Reason for referralAny additional support needsi.e. childcare restrictions, health issues, dietary requirements/allergies, learning difficulties etc. Referrer NameReferring OrganisationReferrer Contact NumberReferrer 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
