Step 1
Step 2
Step 3
Step 4
1/4
First Name
Last Name
Gender
MaleFemaleNon-BinaryTransgenderIntersexI prefer not to sayOther
Date of Birth
Mobile Number
Would you like your identity to be anonymous?
yesno
Home Address
Emergency Contact Name
Relationship to You
Emergency Contact Number
Why would you like to share your mental health story?
How is your mental health in general at the moment?
Please select any of the following you have had struggles with: (multiple selection)
anxietydepressionphobiasdrugs/alcoholabusedomestic violencebullyingself harmfinancial problemssuicidal thoughtsbody-imageeating disordersrelationshipsaddictiongender identityracismrecoveryother
If checked "Other" above please describe
Optional - Please specify on any conditions selected above
0%
We are asking you these questions to help us understand how you're feeling at the moment, and whether it's in your interests to participate in the project.
Please select from the dropdown that best describes your experience of each over the last 2 weeks.
I’ve been feeling optimistic about the future: None of the timeRarelySome of the timeOftenAll of the time
I’ve been feeling useful: None of the timeRarelySome of the timeOftenAll of the time
I’ve been feeling relaxed: None of the timeRarelySome of the timeOftenAll of the time
I’ve been feeling interested in other people: None of the timeRarelySome of the timeOftenAll of the time
I’ve had energy to spare: None of the timeRarelySome of the timeOftenAll of the time
I’ve been dealing with problems well: None of the timeRarelySome of the timeOftenAll of the time
I’ve been thinking clearly: None of the timeRarelySome of the timeOftenAll of the time
I’ve been feeling good about myself: None of the timeRarelySome of the timeOftenAll of the time
I’ve been feeling close to other people: None of the timeRarelySome of the timeOftenAll of the time
I’ve been feeling confident: None of the timeRarelySome of the timeOftenAll of the time
I’ve been able to make up my own mind about things: None of the timeRarelySome of the timeOftenAll of the time
I’ve been feeling loved: None of the timeRarelySome of the timeOftenAll of the time
I’ve been interested in new things: None of the timeRarelySome of the timeOftenAll of the time
I’ve been feeling cheerful: None of the timeRarelySome of the timeOftenAll of the time
33%
Tell us about you. Who are you? What's your background? What brought you to this place today?
What started your mental health journey?
How did it feel going through what you went through? How did it affect your behaviour and your lifestyle?
What key moment changed things for the better? What coping strategies? What helps you in times of struggle?
What advice would you give to someone going through something similar to your experience?
Would you like us to create a video to express your story/part of your journey?
66%
By submitting this form I consent for SAFA Cumbria to read and review the data that I have submitted, to store it for as long as necessary to process my application, and to contact me about it.
[cf7ic]
* by submitting this form you are consenting to providing the data outlined above.
Back
100%
Subscribe to SAFA and get the latest news and event updates.