MANI Initial Contact Form
Mentally Aware Nigeria Initiative is a non-profit organisation aimed at reducing stigma and increasing
awareness on mental illness among Nigerians. To do this, they have a team of in-house counsellors that
work for them to deal with various cases ranging from suicide intervention to feeling of loneliness,
needing someone to talk to or just seeking support in any way.

This form is for us to get the necessary information about you, so we can match you to a counsellor best suited for you.
(The information provided here is treated with utmost privacy).

Please only fill this form if you are the (we do not accept referrals, you are unable to fill this form on behalf of someone else).

What would you like us to call you? (May not be your real name) *
Your answer
Have you used our counselling service before? (PS this is solely for admin purposes) *
Email address
Your answer
Social Media Handles (Twitter/Instagram/Facebook) *
Your answer
WhatsApp Active Phone number *
Your answer
If you are not on whatsApp, kindly drop your phone number below
Your answer
How old are you? *
Do you consider yourself: *
What challenge can we help you with? (If your immediate challenge is not among the options below, kindly chooose one closest to it) *
Country of residence *
State of residence (if Nigeria) *
Here at MANI, we only offer short term services, Thus, each client is only entitled to five (5) sessions. Please select yes to confirm that you understand this requirement. (you can select the 'other' option to drop us any comments you might have regarding 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)
Thank you for filling this form, we promise to get one of our in-house counsellors to contact you (preferably via WhatsApp) within the next 24 hours.

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 counselling and might refer you to mental health facilities for further evaluation and treatment by mental health specialists.

Note that by filling and submitting this form, you agree to the set out terms and conditions of our service provision.

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