Be involved - Improving Stroke Services in Coventry and Warwickshire

Be involved

Please tell us your name

Please tell us about yourself. Are you:

If other, please state:

How would you like to be involved?

receive the e-newsletter

be invited to meetings and events

share my experience with you

Please provide your contact details:

Email address:Our preferred method for regular contact is via email. Please provide an email address if you have one so that we can add you to the e-newsletter mailing list.

Address:

Telephone number:

Your personal characteristics:

By collecting this information we will be able to provide evidence that we are reaching the people that need particular services and identifying when we are not. It can help us understand possible barriers to services and areas for improvement. All information is confidential and used for statistical purposes only.

Age:

Sex

Ethnicity

Other ethnicity - please state:

Language

If other, please state language:

How well can you speak English?

Religion/belief:

If other religion, please state:

Do you consider yourself to have any of the following? (Please tick all that apply)

Mental health condition

Speech impairment

Physical impairment

Sensory impairment

Cognitive impairment

Learning disability

Long term condition

Learning difficulty

Sexual orientation

If other, please state:

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

I consent to my information being used for the purposes described above and wish to submit this online form to Improving Stroke Services in Coventry and Warwickshire • Westgate House, Market Street, Warwick, CV34 4DE.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.