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    LIVED EXPERIENCE PARTICIPANT

    Participant Information

    First Name

    Last Name

    Gender

    Date of Birth

    Mobile Number

    Would you like your identity to be anonymous?

    Home Address

    Emergency Contact

    Emergency Contact Name

    Relationship to You

    Emergency Contact Number

    Your Story





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    WELLBEING FORM

    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.

    Below are some statements about feelings and thoughts.

    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:

    I’ve been feeling useful:

    I’ve been feeling relaxed:

    I’ve been feeling interested in other people:

    I’ve had energy to spare:

    I’ve been dealing with problems well:

    I’ve been thinking clearly:

    I’ve been feeling good about myself:

    I’ve been feeling close to other people:

    I’ve been feeling confident:

    I’ve been able to make up my own mind about things:

    I’ve been feeling loved:

    I’ve been interested in new things:

    I’ve been feeling cheerful:

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    YOUR STORY






    Would you like us to create a video to express your story/part of your journey?

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    Data Protection

    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.

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    * by submitting this form you are consenting to providing the data outlined above.

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