Basic Information Form

If you are interested in getting some counselling then all you need to do is either:

  • Complete the form below and click "submit". The details on the form will then be emailed to us
  • Download the form, print it and complete the details by hand, then post it to us at Mankind, 1 Brunswick Road, Hove, BN3 1DG
If you are unable to complete the form then just call us on 01273 911680 and we can fill it in for you over the phone.

Fields marked * must be completed
At least one of the fields marked ** must be completed

Contact Details Ok to write?
Name*

Yes
No
Address*
Town*
County
Post Code*
Date Of Birth dd/mm/yy
Phone Details:
Ok to leave messages?
Home**

Yes
No
Mobile**

Yes
No
Other**

Yes
No
E-mail Details Ok to E-mail?
E-mail**

Yes
No
How did you find out about our service?*
What are you looking for from our service?
What issue is a service sought for?
Childhood Sexual Abuse
Adult Sexual Abuse
Adult Rape
Other
What type of service would you like?
1-1 Counselling
Couple Counselling
Therapeutic Group
Creative Therapeutic Group
If other please state below:
I confirm that I am the person named in this form or have given permission for someone else to contact you on my behalf*