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Intervention Expression of Interest Form
Please complete this form if you would like to express an interest in being a part of the Jonah's Project CIC Peer Hearing. If you would like to share anything further with us please feel free to email us
interventions@jpinterceptionhub.co.uk
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* Indicates required question
Intervention Leaflet Page One
Intervention Leaflet Page Two
Contacts Full Name
*
Your answer
Company Name
*
Your answer
Company Address
*
Your answer
Contact Email
*
Your answer
Contact Number
*
Your answer
Type of Business
*
Charity
CIC
Limited Company
Statutory Body/Local Authority
Other:
Required
Type Of Service
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Therapuetic
Community
Both
Required
Who Are Your Target Group?
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Young people aged 11-17
Young Adults aged 18-25
Parents/Families
Other:
Required
Which Part of Birmingham do offer services to? (tick all that apply)
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North Birmingham
East Birmingham
West Birmingham
South Birmingham
Required
Please Specify the main areas you cover (eg. Kings Norton, Accocks Green, Balsall Health)
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Your answer
Nature of Your Service (tick all appropriate)
*
Mentoring
Sports
Music
Youth Club
Workshops
Other:
Required
Brief Description of Your Service
*
Your answer
What is your hourly rate fee?
*
Your answer
Submit
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