Consent Form

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Blesma, The Limbless Veterans Consent Form, in association with Warwick-Edinburgh Mental Wellbeing Scale Questionnaire

To help us understand if taking part in our Outreach programme has made any changes to your wellbeing, we would like you to answer a few questions about your wellbeing. We will ask these questions now and again during the new few months. The questionnaire on the next page will consist of 14 questions which will take about 8 minutes to complete. We would be very grateful if you would help us with this evaluation.

I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason. *

I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason.

I confirm that I understand what the study is about and have had the opportunity to ask questions. *

I confirm that I understand what the study is about and have had the opportunity to ask questions.

I agree to take part in this evaluation. *

I agree to take part in this evaluation.

Blesma Member’s Code Number (If known)

Name of Participant *

Email address

E-Signature

Date

We can help

We are dedicated to assisting serving and ex-Service men and women who have suffered life-changing limb loss or the use of a limb, an eye or sight. We support these men and women in their communities throughout the UK. Click the link below to find out the different kinds of support we offer.

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