🔶SECTION 1 — WELCOME & PRIVACY NOTICE

Welcome Message

Hi! We’re really glad to have you here. This form helps us understand your situation, strengths, challenges and goals so we can support you properly.

Your information is kept private, safe and only shared with the with the GLA and their authorized research partners for support and monitoring purposes.

1.1. Privacy Notice Confirmation (Required) *

Your data will be handled in accordance with UK data protection laws.

GLA to ensure eligibility for funded programme

Please tick the box to agree to this Trailblazer Form

For full details on how we use and protect your information, please see our complete Privacy Notice: https://www.findyourfeetcic.org.uk/privacy-policy

Signature (typed or drawn): *

Clear

Date

1.2 Which session are you signing up for? *

🔶 SECTION 2 — ABOUT YOU

Full Name *

2.2. Preferred Name (if different) *

2.3. Date of Birth

2.4. Age

2.5. Phone Number *

2.6. Email Address *

Address

Street Address

City

State

Country

Postal Code

2.8. Emergency Contact *

Name:
Phone:
Relationship:

2.10. Are you currently living in social housing or supported by a housing association? *

Yes

No

Prefer not to say

2.11. If yes, which Housing Association are you part of? (Tick all that apply)

If Other, please specify:

Sharing this information helps us understand where additional support, opportunities or resources may be available, depending on housing provider. This will not affect your eligibility to take part.

🔶SECTION 3 — CARE EXPERIENCE BACKGROUND

3.1. Are you care-experienced? *

Yes

No

3.2. Your current status: *

3.4. Do you feel confident contacting your PA? *

Yes

Sometimes

No

🔶 SECTION 4 — YOUR CURRENT SITUATION

4.1 To help us tailor our support, please select the group(s) you identify with (Select all that apply):

4.3 Do any of the following currently impact your daily routine or ability to participate? *

🔶 SECTION 5 — EDUCATION, WORK & SKILLS

5.1 Highest level of ESOL qualification (if applicable) *

No ESOL Qualification (Native speaker or no formal testing)

Entry Level / Level 1 (Basic to intermediate communication)

Level 2 or Higher (Fluent / Advanced / Professional use)

5.1.2 Highest qualification *

If Other, please specify:

5.2. Work Experience *

Yes

No

If yes, what type?

5.3. Do you have a CV? *

Yes

No

Needs updating

5.4. Do you have:

NI Number *

Yes

No

ID (passport/BRP/license) *

Yes

No

5.5. What skills do you feel confident in? *

🔶 SECTION 6 — BARRIERS + SUPPORT NEEDS (TRIAGE)

(This section helps us identify extra support and safeguarding.)

6.1. What challenges are you currently facing? (Select all) *

If Other, please specify:

6.1.1 To help us understand your specific needs, please tell us if any of the following apply to you (Select all that apply): *

If Other, please specify:

6.2. Do any of these feel urgent or serious? *

Yes

No

If yes, please describe (for triage):

6.3. Are you receiving support from anywhere else? *

If Other, please specify:

🔶 SECTION 7 — HEALTH / SEND / EMOTIONAL WELLBEING

7.1. Do you identify as having any SEND or additional needs? *

7.2. How is your emotional wellbeing right now? *

7.3. Anything we should be aware of to support you safely? *

🔶 SECTION 8 — COMMUNICATION & SUPPORT STYLE

8.1. Best days for sessions *

8.2. Best times for sessions *

8.3. How do you like to be supported? *

8.4. Anything that makes support easier/harder for you? *

8.5 In your own words, what would you like to get out of this session or programme?

🔶 SECTION 9 — CONSENT & SIGN-OFF

By signing below, you confirm:

You understand the programme
You agree to participate voluntarily
You understand your data rights
You know how to contact FYF if you have concerns

Participant/Referrer Signature: *

Clear

Participant / Referrer Full Name *