Pre-Chat Form - Helpline hours are 4pm to 11pm
Here at The Mix we offer a confidential service. That means we don’t tell anybody outside of The Mix what we have talked about. However, if we felt that you or anyone else was in danger, then we may have to break this.
If this were the case we would tell you the conversation wouldn’t be confidential and ask for your details if we haven’t got them already. You can read more about our policies
here
.
First name:
Last name:
Email:
Phone:
Issue:
How old are you? *
How old are you? *
0-6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26+
Prefer not to say
Whats your ethnicity? *
White English/Welsh/Scottish/Northern Irish/British
White Irish
Gypsy/Traveller
Any other White background
Asian and Black African
Asian and Black Caribbean
White and Asian
White and Black African
White and Black Caribbean
Any other Mixed background
British Asian
Indian
Pakistani
Bangladeshi
Chinese
Japanese
Any other Asian background
Black British
Black Caribbean
Black African
Any other Black background
Arab
Any other ethnic background
N/A due to confidentiality
Prefer not to say
Whats your gender? *
Male
Female
Transgender
Prefer not to say
Other
How did you hear about us? *
Facebook
Twitter
YouTube
Social Media - Other
Google
Bing
Search Engine - Other
Our Website
Website - Other
ITV
BBC
NOW TV - I am an employee
NOW TV - I am a viewer
TV - Other
Capital Radio
Kiss FM
Radio - Other
Metro
Financial Times
Newspaper - Other
Magazine - Other
ChildLine
Organisation - Other
Family
Friend
School
Mobile App
Phone Directory
Leaflet/Flyer
Poster
Doctor/MedicalCentre/Hospital
Teacher
Police
University Channel
Challenge
Prefer not to say
Other
Which of these describes your mood? *
Alone
Angry
Annoyed
Anxious
Ashamed
Bitter
Confused
Depressed
Disappointed
Dissatisfied
Distrustful
Down
Embarrassed
Empty
Excited
Fed up
Frustrated
Guilty
Happy
Hostile
Impulsive
In despair
Indignant
Inferior
Irritated
Isolated
Lonely
Lost
Low
Need help
None suitable
Powerless
Sad
Sense of loss
Stressed
Tired/Lethargic
Unwell
Upset
Useless
Vulnerable
How low are you feeling right now? *
6 - Fine
5
4
3
2
1 - Very low
Where do you live? *
Channel Islands
East Midlands
East of England
Isle of Man
London
North East England
North West England
Northern Ireland
Scotland
South East England
South West England
Wales
West Midlands
Yorkshire and the Humber
Outside of the UK(Overseas)
Prefer not to say
Can we contact you in the future? *
Yes
No
By ticking this box, you are agreeing that we can process and store your data to provide you with a webchat service. We keep a copy of all of our webchat transcripts and we use information about you to make sure that we can provide our webchat service in the best possible way. You can read more about how we store helpline data
here
and situations when that might change in our
Confidentiality Policy
.*