Fill In

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 who will contact you by telephone within the next 7 days, and will not be passed on to anyone else without your consent to do so.

What areas would you like advice, support or help on? (Please tick all that apply) ^*

I want to increase my level of physical activity or become fitter, but don't know where to start
I need to lose weight
Finding out more about healthy eating
Becoming more active as a family
Advice on stress, anxiety and becoming overwhelmed
Stopping smoking
I would like a health MOT - blood pressure checked, cholesterol and weight measured, as well as checking for diabetes

Is there a specific problem or question you would like help with?

Follow the links below to find out more about the topics:

Being overweight

Being inactive

Unhealthy diet

Smoking too much

Drinking too much

Drug abuse

About You

Your Name

Are you

Male

Female

What is your ethnicity?

What age range are you in?

Which neighbourhood do you live in?

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:

Contact details

What is your preferred method of contact?

Telephone

Email

Phone number:

Email address:

Crawley Borough Council complies with the Data Protection Act 1998 and the Freedom of Information Act 2000