Thank you for helping us by completing this vital survey. It provides us with valuable information in helping us to secure funding to serve women in our community.

Securing funding supports the delivery of our programmes to more people that may not be in a position financially to receive this much needed support.

If you are a woman that needs some support please complete this survey before you complete the application process.

Thank you so much for your help.

Wellness CIC Team

Full Name

Phone *

Email *

This information is private and confidential - you can find our privacy policy and GDPR statement on our website wildwarriorwellbeingcic.co.uk. This information maybe used in case study evidence to demonstrate to funders.

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from Wild Warrior Wellbeing CIC . You can reply STOP to unsubscribe at any time.

What is your Post code? *

Description of Mental health is a state of mental well-being that enables people to cope with the stresses of life, realise their abilities, learn well and work well, for themselves and contribute to their community.

How often do you experience feelings of Anxiety *

Rarely

Sometimes

Often

Always

Anxiety is a feeling of worry, nervousness, or unease about something with an uncertain outcome:

If you are in a personal and sexual relationship. How does it feel? Choose the option that applies to you the most closely. *

Perfect, couldn't be better on all levels

Good I feel loved and love

Okay, we have good and not so good times

We aregue, disagree a lot, doesn't feel good

We don't talk most of the time and have no deep connection

We are not connected emotionally but we still have sex

We are connected emotionally but we don't have sex

Its an abusive loveless relationship

Im not in a Relationship

Depression is a medical condition in which a person feels very sad, anxious and without hope and often has physical symptoms such as being unable to sleep, etc

How well do you sleep at night? Choose one that applies closest to you *

Very Well and I feel fresh throughout the day

Well - sometimes wake up once through the night

Moderately - it's Okay, can be broken at various times during the month

Poorly - I sleep less than four hours a night

I am continuously tired and still need more sleep

I sleep the majority of the day and night

My sleeping pattern is all over the place

It is recommended we have between 6 to 8 hours of sleep for a healthy life. Please note that everyone is different and these are guidelines only.

Have you experienced any trauma in your life?

Yes

Unsure

Symptoms of trauma can be both emotional and physical. The emotional response may lead to intense feelings that impact a person's attitude, behavior, functioning, and view of the world. Trauma can be characterised by a belief that life and safety are at risk with feelings of fear, terror, or helplessness. Trauma is not the actual event that happened, its the response to the event. Trauma can come as something such as physical, sexual abuse and grief (known as a Big T) or something such as rejection from family or friends as a child or told you were 'stupid'.

If you have answered Yes or Unsure to the previous question, please describe briefly. *

Do you enjoy your life? *

Yes

Sometimes

Do you attract unsafe or unavailable people? *

Yes

This is resonating but I am not sure

Unsafe and unavailable examples could be partners or friends who may be chaotic, who may cause you harm emotionally, physically, sexually, financially or people already with another or other sexual partners

How much time do you make for yourself? *

Always

Most of the time

Sometimes

Never

for example; self care, sleep, work, rest, out in nature, out with friends, walking, meditation, exercise, time to eat

Do you feel isolated , lonely or a sense of disconnect? *

Yes

for example - feeling lonely, like you have no one to ask for support or no one to speak to about whats going on in your life, disconnected from other people - even though you have friends and family around you, not sure of your passions, dreams, love of self.....

Do you feel burnt out, exhausted or stressed ? *

Always

Sometimes

Never

Do you have a healthy work life balance ? *

Yes

Most of the time

Sometimes

Do you feel safe within your environments or relationships?

Always

Sometimes

Most of the time

Never

Are you suffering with grief? *

Yes

Grief is the anguish experienced after significant loss, usually the death of a beloved person. Grief often includes physiological distress, separation anxiety, confusion, yearning, obsessive dwelling on the past, and apprehension about the future. Intense grief can become life-threatening through disruption of the immune system, self-neglect, and suicidal thoughts. Grief may also take the form of regret for something lost, remorse for something done, or sorrow for a mishap to oneself.

Do you feel at times overwhelmed with guilt, shame, resentment or anger ? *

Yes

Most of the time

Sometimes

Are you employed? *

Yes

Would you like support finding employment or changing your job?

Yes

Do you feel financially secure ? *

Yes

Financial security refers to the peace of mind you feel when you aren’t worried about your income being enough to cover your expenses. It also means that you have enough money saved to cover emergencies and your future financial goals

Do you suffer with addiction? *

Yes

For examples - the condition of being addicted to a particular substance or activity: such as gambling, sex, alcohol, drugs, social media and phone use

Do you suffer with Chronic Pain? *

Yes

examples of chronic pain include, arthritis or joint pain, back pain, next and shoulder pain, fibromyalgia. headaches, including migraines etc

Do you know what contributes to your stress and anxiety. if so please share. If not applicable please write n/a

Please share with us any physical, mental or emotional issues, challenges or illnesses you have which you need support for.

Do you believe that you can improve your habits and routines with structure, organisation and awareness? *

Yes

Do you believe learning meditation and breathing exercises will help create a positive impact on your well-being. *

Yes

How often do you walk in nature? *

Every Day

More than 4 times a week

Less than 4 times a week

Less than 1 day a week

If you have children, do you feel you could acquire new skills to help you communicate with them better? *

Yes

I would love to but don't know how

If you answered Yes to the last questions please describe briefly how this would help. *

Are you taking any medication to support your Mental, emotional and physical health ? If so please share if you are also wishing for holistic practices to support you whilst on them or through withdrawal.

Have you been offered any support from your GP or current Health Care provider *

Yes

Are you on a waiting list from your GP or Health Care Provider? If so select the duration of expected wait times *

0-3 months

3 to 6 months

6 to 12 months

over 12 months

Answer the following questions if you feel you need support from one of our programmes. What is the main reason for wanting to Join one of the Wild Warrior Wellness CIC Programmes? Please be as honest as possible so we can support you with the best programme for you. *

Please tell us which programme is more suitable for you. *

Online

In Person

Both work for me

Can you travel to an In person programme? If not also state below if you would prefer an alternative programme, such as online or other *

I can travel

Online is best for me

An alternative programme

Do you wish to apply for a place on one of our programmes *

Yes I need a Fully Funded space (£1200)

Yes I need a space but can part fund £300 towards the cost

Yes I am happy to invest in my wellbeing in full (£1200)

No thanks so much

No thanks but I would love to sponsor a space for someone else.