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How old are you?
   
 
 
 
What is your ethnicity?
 
 
 
What is your religion?
   
 
 
 
What is your marital status?
 
 
 
What is your sexual orientation?
 
 
 
Do you have any disabilities or long term conditions? (E.g. dyslexia, diabetes). Please list.
   
 
 
 
Where did you find out about our service?
   
 
 
 
Where else do you think would be a good place for us to be visible (e.g. through advertising) so you could have found out about our service from there (e.g. a poster at the gym) and then referred yourself to us? [Please list as many as you can think of]
   
 
 
 
Were you hesitant about initially contacting our service?
 
Yes
 
No
 
 
 
If you were hesitant, what made you eventually decide to give us a call?