Registration Form - Stand Alone

In order for us to best understand how to support you in our groups and workshops, it’s important that we gather some information about you, your estrangement and your wellbeing. This should take no more than 5-10 minutes to fill in. Please be aware we won’t be able to respond to your personal circumstances at this stage, but this form will allow you to access our groups and workshops, where you can find support with your situation.

First Name

Last Name

DOB

Phone

Mobile

Gender

Address

Street and House no

Town

County

Postcode

Emergency Contact

Emergency Contact Phone

Who are you experiencing estrangement from?

How long have you been experiencing estrangement?

Tell us about your estrangement in your own words (200 words)

Please describe your thoughts on reconciliation

Other thoughts on reconciliation, please specify (2 lines maximum)

Are you currently seeing a counsellor, therapist or psychologist?

GP’s name and address (optional)

Have you ever been diagnosed with any of the following? (press Shift to select multiple)

Have you been prescribed medication in relation to this diagnosis?

Name of medication

Tell us about your wellbeing strategies. How do you look after yourself? (press Shift to select multiple)

Tell us about your support network

Please set three goals for your involvement with Stand Alone…

Your confidentiality is important to us, by clicking submit you are agreeing that Stand Alone can safely and securely store your data in our encrypted database.

Your details will only be seen by the therapeutic group leaders in your local area and staff associated directly with the project. We will never pass your details to a third party or use it other than for its prescribed purpose of registering you with a support group. We strictly adhere to all data regulation from the charities commission.

Need assistance with this form?

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