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Frank Ltd.
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Keeping Well NWL
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What is your full name?
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What is your date of birth?
Required
What is your telephone number?
Required
What is your email address? Please note: There is a chance that emails from us may get filtered into your junk mailbox – please check this over the next week if you haven’t heard from us
Required
Can you let us know the best time of day to call?
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Do you give permission for us to leave a voicemail and / or send a text message?
Required
Yes
No
What is the best method to contact you?
Phone
Email
What is your gender?
Required
Please choose an option from the list
Male
Female
Transgender
Non-binary
Prefer not to say
What is your ethnicity?
Required
Please choose an option from the list
White British
White Irish
Any other White background
Black or Black British
White and Black African
White and Black Caribbean
Caribbean
African
Any other Black background
Asian or Asian British
Pakistani
Indian
Bangladeshi
Any other Asian background
Any other mixed background
Any other ethnic group
Mixed background
Prefer not to say
What area do you work in?
Milton Keynes
Luton
Bedfordshire
What sector do you work in?
NHS
Local authority (social care)
Care homes or care agency
Police
Teaching
Fire service
Voluntary, Community and Social Enterprise Sector
What is your job role?
Have you been redeployed due to Covid-19 or are working in a vaccination centre?
Yes
No
Which of the following best describes why you are accessing the service?
Required
Please choose an option from the list
Mood difficulty
Bereavement
Work stress
More than one difficulty
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