C/O/R/E PROJECTSELF REFERRAL Please note – CORE doesn’t currently have childcare facilities, but under 1’s can sometimes accompany their father/carer to some of our sessions. Please ask for more information if this is applicable to you. First Name *Last Name *Email AddressPhoneWhat is your preferred method of contact?PostcodeDate of BirthAgeWhy are you interested in the CORE Project? (please tick all that apply)I am experiencing loneliness and/or isolationI'm looking for support with my anxiety / mental health issuesI'm looking for support with my confidence and/or resilienceI've had previous experience of domestic abuseI'm looking for support with my physical wellbeingI'm interested in the crafts and activities availableI'm interested in the courses availableI'm interested in skills and training opportunitiesI'm interested in volunteeringOther (please provide details below)So we can make reasonable adjustments, do you have any health conditions (medical, mental health, learning or specific physical conditions we need to be aware of? e.g. epilepsy, diabetes, allergies)YesNoIf yes, please provide detailsDo you have any dependant children?YesNoIf yes, how many and how old are they?Are you a named Carer?YesNoAre you currently working with any other agencies?YesNoIf yes, please provide detailsWhich kind of property are you currently living in? (private rented, housing association, owned etc)Are you currently working, studying, other?If working/ studying, what is your work/study pattern? What time of day would you prefer to access the CORE Project?Do you have any dietary preferences?Please give any other information you feel the CORE Project would benefit from knowingWhich ethnic group do you identify with?Submit