MANI Initial Contact Form
Hello, will you love to chat with one of our in-house volunteer counsellors? Please do fill the form below and we'll be in touch as soon as we can.
If no one reaches out to you, kindly let us know here so we can follow up. If it's an emergency, do call or leave a text on 08091116264, 09060097915 or 08111680686
Just to clarify, the service we offer is free, our counselors aren't therapists but volunteers with experience in the medical/health sector, who are trained to listen to and support you. If your experiences with them don't go as well as you would have hoped, could you do us a favor and send a mail to
, we will assign you to a different counselor or connect you to our resident therapist.
If you are still willing to go ahead with this service, please be patient with us as we are dealing with an influx of cases and will assign you to a counselor within 7 days of filling this form
Name (This can be your nick name or an Alias)
Social Media Handle
Next Of Kin Contact Number
WhatsApp Active Phone number
If you are not on whatsApp, kindly drop your phone number below
How old are you?
Less than 18
46 and above
Do you consider yourself:
Prefer not to say
What challenge can we help you with? (If your immediate challenge is not among the options below, kindly choose one closest to it) - If you have chosen any of the marked options, we may reach out to you via a voice call.
I feel like life isn’t worth it.
I just lost someone who was dear to me.
I just lost my job.
I need help to deal with an abuse by a partner
I need help to deal with a traumatic experience
I feel depressed.
I need help to stop smoking or drinking
I need guidance with my career or academics
I need help managing stress
I need help coping with a breakup
I need help managing my weight
I need help managing my pain
I have not been getting adequate sleep
I feel that I am a lesbian, gay, bisexual or Transgender (LGBTQ) and I need to talk to someone who won’t judge me
I need help handling my emotions
I need to talk to a professional about my relationship
I need help maintaining sobriety
I have a gambling problem
I feel like I'm having a panic attack*
I just want to talk to someone who cares*
I feel like ending it all*
Country of residence
State of residence (if Nigeria)
Federal Capital Territory ( Abuja )
Are you LGBTQ? (This is to help us assign you to an appropriate counsellor)
Is this the first time you're using our service?
Here at MANI, we only offer short term services, Thus, each client is only entitled to 2 meetings. Please select yes to confirm that you understand and agree to this
Referred From? (Skip this if you got this form from any @MentallyAwareNG platforms, but if you didn't, please do indicate which of the organizations below referred you and If Other, please type name of organization)
The Consent WorkShop
Stand To End Rape
Billboard, Newspaper/Print Media
We are collating responses and feedback for our "WhatSupportMeansToMe" campaign which we would post on our social media pages. It would mean a lot to us if you get involved. Tick below to opt out or in?
Thank you for filling this form, we promise to get one of our in-house counsellors to contact you (via WhatsApp/phone call) within 7 days of filling this form.
Our services serve to deescalate, counsel and when necessary, refer you to specialist facilities. Your counsellor will work with you to provide psychological first aid and might refer you to mental health facilities for further evaluation and treatment by mental health specialists.
Please, note that you shouldn't give out or share the contact of the counsellor assigned to you.
Note that by filling and submitting this form, you agree to the set out terms and conditions of our service provision.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service