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 crisis@mentallyaware.org, 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

Thank you.
Sign in to Google to save your progress. Learn more
Email *
Name (This can be your nick name or an Alias) *
Social Media Handle *
Next Of Kin Contact Number *
WhatsApp Active Phone number *
WhatsApp Active Phone number *
If you are not on whatsApp, kindly drop your phone number below *
How old are you? *
Required
Do you consider yourself: *
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. *
Country of residence *
State of residence (if Nigeria) *
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) *
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? *
Required
Promise!!!
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.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms