Inclusion and Diversity Monitoring Survey

Gaia House warmly welcomes all people of every age, ethnicity, cultural heritage and religious background, socio-economic group, ability, sexual orientation and gender identity.

As such, we are committed to identifying, understanding and taking down whatever barriers might prevent the inclusion and participation of people of diverse identities. A key part in this process is inquiring into where we are now, as well as tracking our progress as we work towards improving both accessibility and inclusivity.

We would be very grateful if you could answer the questions below to assist us in this important work. The survey is anonymous and the data you share with us will not be passed on to anyone else.

Gender Female ☐ Male ☐ Prefer not to answer ☐

Another gender identity Please write in, if you choose: …………………………………………

Age	16-24	☐	25-34	☐	35-44	☐	45-54	☐	55-64	☐ 65-74	☐	75 +	☐	Prefer not to answer ☐

What is your ethnicity?

Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box.

I prefer not to answer ☐

Asian/Asian British

Indian ☐	Pakistani ☐ Bangladeshi ☐	Chinese ☐

Another Asian background ☐ Please write in, if you choose: ………………………….

Black/ African/ Caribbean/ Black British

African ☐	Caribbean	☐

Another Black/African/Caribbean background ☐ Please write in, if you choose: …………..

White

English ☐	Welsh ☐ Scottish ☐ Northern Irish ☐ Irish ☐

British ☐ Gypsy or Irish Traveller ☐

European ☐ Please write which European country…………………………

Another white background ☐ Please write in, if you choose: ………………..……..

Mixed/multiple ethnic groups

White and Black Caribbean	☐	White and Black African ☐ White and Asian ☐	Another mixed or multiple ethnic background ☐ Please write in, if you choose: ………….

Other ethnic group

Arab	☐	Another ethnic group ☐ Please write in, if you choose: ………………………….

What is your country of residence? ……………………………………..

How long have you lived there?

Whole Life ☐ More than 10 years ☐ Less than 10 years ☐	Prefer not to answer ☐

Do you have a disability, long-term illness or health condition?

Yes ☐ No ☐ Prefer not to answer ☐

If yes, please describe, unless you prefer not to answer:

…………………………………………………………………

What is your sexual orientation?

Bisexual ☐	Gay woman/lesbian ☐ Gay man ☐	Heterosexual ☐

Another orientation ☐ Please write in, if you choose: ………………………………….

Prefer not to answer ☐

Do you consider yourself as being affiliated with or belonging to a religion?

No Religion or Belief

Another religion or belief ☐ Please write in, if you choose: ………………………….

Prefer not to answer ☐

Please indicate your approximate annual household income, whether from work, pension, benefits, investments, etc. This includes income from other adults in your household as well as you.

Choose an item.

Prefer not to answer ☐

How many people does this income support (including you, other adults and children)?

Choose an item. Prefer not to answer ☐

Given all your financial commitments, is the standard cost of coming on a retreat at Gaia House for you:

Choose an item.

Have you filled in this form in the last 12 months? …………….

With many thanks.

Please fold your completed form in half and post in the sealed box.