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Support Form
1. What is your name? (You may use your preferred name)
2. What are your pronouns?
3. How old are you?
4. Are you a NSW resident?
Yes, I live in NSW!
No
5. Postcode
6. Which would you prefer us to contact you with?
Mobile
Email
Either/Both
7. What is your best email to contact you?
8. What is your best mobile number to contact you?
9. I identify as…
Muslim
Middle Eastern
North African
South Asian
LGBTIQA+
Speaking a language at home other than English
Living with a disability or chronic illness
None of the above
10. What kind of support are you most interested in? (You may select a few)
1:1 Mental Health Support (In-person)
1:1 Mental Health Support (Via Zoom or Phone Call)
Groups and events for meeting other BIPOC Queer and Trans youth
Group Art Therapy
11. What's going on for you at the moment that we can help with?
12. What times would you be free for a chat? We currently have availability during business hours from Monday to Friday, so please feel free to be specific about what times work for you.
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