CWTCH Cymru Contact Form

Welcome to CWTCH Cymru (Communities Working Together Can Help). Please complete this form so we can get to know you a little better and to help us understand your needs.

1. What is your name? *

Title	*
First name	*
Last name	*

2. Please add your contact details: *

Address Line 1	*
Address Line 2
Town/City
Welsh County	*
Postcode	*
Contact Telephone Number (Landline or Mobile)	*
Alternative Contact Telephone Number (Landline or Mobile)
Email Address (if applicable)

3. Please enter your date of birth: *

	DD/MM/YYYY
Date of Birth:

4. What is your gender? *

Female
Male
Prefer not to say
Prefer to self-describe

5. Emergency contact details

Name
Contact Telephone Number (Landline)
Contact Telephone Number (Mobile)

6. Do you currently have any of the following conditions? (Please tick all that apply)

Inflammatory arthritis or autoimmune disease in joints, bones, or muscles (e.g. rheumatoid arthritis, ankylosing spondylitis, lupus etc.)
Osteoarthritis
Chronic or long‐term / ongoing joint pain (i.e. pain or discomfort that you have all of the time, or on and off for at least the last three months)
Osteoporosis / thinning or weakening of the bones and/or fragility fractures
Other (please state):

7. Which of these following statements best describes where you are on your journey with arthritis?

I have not yet been diagnosed
I am awaiting a diagnosis
I have been diagnosed and have just started treatment
I have been diagnosed and have already started treatment, and I'm now waiting for it to take effect
I have been diagnosed and my condition(s) is currently under control using treatment
I have been diagnosed and I am currently changing and/or adding to my treatments
I have been diagnosed and I manage my condition(s) myself

8. Overall, how would you rate the impact of your arthritis on your day-to-day life?

9. What support do you require from Cymru Versus Arthritis?

10. How did you first hear about Versus Arthritis / Cymru Versus Arthritis?

Other (please state):

11. The CWTCH Cymru project is planning to collect and store contact information for all participants taking part in activities on our database. We will share this information with our CWTCH Cymru Volunteers so that, in case of an emergency, they can get in touch with your emergency contact.

Please tell us how you prefer to be contacted: *

Post
Phone
Email

12. An external partner will be evaluating the project, and while we will not share contact details directly with the external partner, Versus Arthritis can contact beneficiaries for evaluation research purposes on their behalf.

If you do not want to be asked to provide feedback, please tick here

13. By filling in your details, we can send you our latest news, updates and ways you can support Versus Arthritis. Don’t miss out on hearing about our latest research, support services and advocacy campaigns, as well as fantastic volunteering, fundraising and event opportunities at Versus Arthritis. Please tell us how you may be contacted. *

Post
Phone
Email
I do not wish to receive this information

You can find more details regarding how we look after your personal data by going to www.versusarthritis.org/privacy

All this information will be treated as confidential.

14. Please indicate below who completed this form, e.g. either yourself on your own (self-referral) or someone filling it in on your behalf. *

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