Crawley Wellbeing Enquiry Form
Everything you tell us in this form is treated in strictest confidence. Your details will only be used by the Wellbeing Team to contact you and will not be passed on to anyone else without your consent to do so.
What areas of wellbeing are you interested in?
*
Drinking
Drugs
Emotional Wellbeing
Food
Physical Activity
Sex and Relationships
Smoking
Working Life
Is there a specific problem or question you'd like help with?
About You
Your Name
Are you:
Male
Female
What age range are you in?
Please Select ...
16 - 19
20 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 - 69
70+
rather not say
Which neighbourhood do you live in?
Please Select ...
Bewbush
Broadfield
Furnace Green
Gossops Green
Ifield
Langley Green
Maidenbower
Northgate
Pound Hill
Southgate
Tilgate
Three Bridges
West Green
Please provide your postcode, so we can see who uses our services. It is for monitoring purposes only and will be treated in strictest confidence.
Postcode:
Do you consider yourself to be disabled?
Yes
No
Disability:
Visually impaired
Hearing impaired
Physical disability
Mental health problem
Learning disability
Other
Ethnic Origin
WHITE
White British
White Irish
Other white
MIXED BRITISH
White and black Caribbean
White and black African
White and Asian
Other mixed
ASIAN/ASIAN BRITISH
Indian
Pakistani
Bangladeshi
Other Asian
BLACK/BLACK BRITISH
Caribbean
African
Other black
CHINESE
Other
Employment
Employed
Student
Unemployed
Retired
Carer
Not working due to sickness / disability
How would you like us to contact you?
Phone
Letter
Email
Phone number:
Email address:
House / Flat number
Street
Neighbourhood
Town/City
Postcode
Crawley Borough Council complies with the Data Protection Act 1998 and the Freedom of Information Act 2000
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