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Enquiry Form
Please include the following information about the person requiring help to enable us to find appropriate services. Tick appropriate boxes so that we can ensure the information is relevant to your needs.
If you would prefer to send an email rather than complete this form, please write to
enquiries@icis-info4life.org.uk
with details of your enquiry.
How did you hear about ICIS?
Please select one …
On the internet
From a statutory service - Education
From a statutory service - County, District or Borough Councils
From a statutory service - Social & Caring Services
From health - GP, health centre
From health - PALS
From health - Hospital, clinic
From a voluntary organisation (eg support group, charity)
From an independent/commercial company
A mailing from ICIS
A mailing from a statutory service
A mailing from a health service
A mailing from a voluntary organisation
At an event or meeting
Yellow Pages
DIAL UK
From a member of ICIS staff
Other
Your name:
Reply email address:
Your phone number:
Your fax number:
If you would prefer us to post information to you, please include your address here. This will mean a short delay in receiving the information, depending on the postal services at the time of sending:
Postcode:
Where is the help needed in West Sussex?
Types of disability or difficulty:
Difficulties due to social disadvantage
Physical disability
Sensory disability
Learning difficulty
Communication difficulty
Mental health problems
Difficulties due to age
Difficulties due to poverty
Age range of person requiring help:
0-5 yrs
6-11 yrs
12-19 yrs
20-44 yrs
45-65 yrs
over 65
Please indicate how you would like the information:
By e-mail
By fax
By phone
By post
In large print
On tape
In braille
In another language
Through an interpreter
Tell us about the help, support or advice you need, and include details of any disability or difficulty (see above) that may apply so that we can identify the appropriate information.
Please include as much detail as possible.
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