Wellbeing Cafe Membership Form

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Social Prescribing Wellbeing Café offers weekly face to face sessions for residents of Waltham Forest aged 18 years or older who experience low mood, anxiety, loneliness, or social isolation and who would like to and are able to attend the sessions in person. You are welcome to attend with a friend or a relative if you feel more comfortable with a bit of extra support. We will ask your support person to fill in a membership form too. The Wellbeing Café is run from four locations across Waltham Forest: we have welcoming, accessible community venues in Chingford, Walthamstow, Leyton and Leytonstone (Leytonstone session is for women only). Wellbeing Cafés offer social time, light refreshments, activities, advice and learning sessions to choose from and are open to members only. Membership is free and limited to 1 term (10-12 weeks) per member so we can offer this opportunity to more people, the members will be signposted and linked to other opportunities – activities, groups, volunteering, learning, and training to progress onto.

Email *

Name *

Phone Number *

Email Address

Post Code *

Address

Age *

18-25

25-35

35-45

45-55

55-65

65+

Prefer not to say

Required

Emergency Contact, Please add name, address and phone number *

Gender *

Male

Female

Prefer not to say

Other:

How many people in your household *

More than 5

Prefer not to say

What is your ethnic group? *

Asian or Asian British - Bangladeshi

Asian or Asian British - Chinese

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British – Other Asian Background

Black or Black British - African

Black or Black British - Caribbean

Black or Black British – Other Black Background

White - British

White - Irish

White - Eastern European

White - Other White Background

Other Mixed Background

Prefer not to say

Do you consider yourself to be disabled under the Equalities Act 2010?
*

A disabled person is defined under the Equality Act 2010 as someone with a ‘physical or mental impairment which has a substantial and long term adverse effect on that person’s ability to carry out normal day-to-day activities.’

Yes

Don't Know

Prefer not to say

Do you live with a long term condition?
*

Yes

Don't Know

prefer not to say

Are you a carer?

Yes

Don't Know

Prefer not to say

Clear selection

Do you have any language or communication needs we should be aware of?

Is there anything you would like us to know about your mental or physical health that will help us to support you? (e.g. access needs, what you find challenging in a new environment or with new people)

What would you like to get from the Wellbeing Cafe?

Tick as many as you like

Social contact

Activities

Building confidence and skills

Self care and health

Employability skills and volunteering

Other:

Please tell us why you want to join Wellbeing Café?

It might be helpful to think about what your goals are and what you would like to achieve. During your membership we will introduce you to other opportunities – wellbeing activities, groups, volunteering, learning and training you can do later on.

GP Surgery and contact details

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