Surname*
First name*
House/Flat number*
Road/Court*
Area
Postcode help
Daytime phone number (if none, put 'none')
Email address
Ethnicity
Please tell us your ethnic background.
British
Irish
other
Other white background (please state)
Mixed
white and black Caribbean
white and black African
white and Asian
other mixed background (please state)
Asian or Asian British
Indian
Pakistani
Bangladeshi
(please state)
Black or black British
African
Caribbean
Any other black background
(please state)
Other ethnic background
Chinese
Vietnamese
Gypsy/Traveller
Any other ethnic background
Other ethnic background
(please state)
Do you consider yourself to be a refugee?
Yes
No
Gender
male
female
Other gender identity
(please state)
Sexuality
heterosexual/straight
gay man
gay woman/lesbian
bisexual
rather not say
Sexuality
other
(please state)
Religion/Belief
Christian
Buddhist
Hindu
Religion/Belief
Christian
Buddhist
Hindu
Muslim
Jewish
Sikh
None
Other
(please state)
Do you consider yourself to have a disability?
Yes
No
If 'Yes' please tell us about the nature of your disability, so
we can ensure our service is fair and accessible:
physical impairment
hearing impairment
visual impairment (that is not corrected
by glasses or contact lenses)
speech impairment
severe disfigurement
mental health problems
learning disability
learning difficulties or literacy/numeracy needs
Has your home been adapted to make it more suitable for a disabled
person to live there? - for example ramps, hand-rails or a stairlift.
(Answer 'yes' if it has adaptations, even
if there isn't a disabled person in your home.)
Yes
No
If 'Yes' what adaptations are there?
Communication needs
Please tell us if you think we need to consider your individual
needs when we communicate with you.
When we write to you
If you have difficulty reading English, or you would like written
information in another way, please tell us how you would like it.
Braille
in large print
on a CD
I would like it sent in my language
(please put the language here)
I would like it sent to someone else (eg family member, carer).
Please put their
name and address here:
When we phone you Would you like us to use:
typetalk
an interpreter
(If no one in your house speaks English,
we can get an interpreter to translate the call)
If you need an interpreter, which language do you speak?
or
would you prefer to be contacted in another way?
When we visit you, or talk with you face-to-face, is there
anything we should know?
I need a British Sign Language (BSL) interpreter to be there
I need an interpreter who speaks my language.
(please say which language)
I would like to know when you are coming so I can have someone else
there with me.
I would like you to knock loudly and give me time to get to the
door
I would like you to use an agreed password
(please
tell us what)
Other
(please tell say what)
Thank you for your answers. You may want to check them before
you send the form.