Contact Our Helpline Service * Indicates required fields Email the Helpline Service In order to fully monitor the helpline service; ensure we are reaching as wide a group as possible and meet the requirements of our funders we need to ask you a few questions. Step 1 of 3 - Contact Information 33% TitlePlease selectMrMissMrsMsDrOtherOther - please stateName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Telephone Number (main)*Telephone Number (mobile)*Email* Enter Email Confirm Email Are you a*Please selectParentRelative/CarerAdult with DyspraxiaProfessionalEmployment statusPlease selectEmployedUnemployedStudentOtherOther - please specifyType of professional*Please selectHealthEducationalEmployerOtherOther - please specifyGender* Male Female Age Range*Please select0 - 2425 - 6465+Ethnic Background*Please selectWhiteAsian/Asian UKMixed Ethnic backgroundBlack/African/Caribbean/Black UKWould rather not sayReligion*Please selectChristianHinduBuddhistJewishSikhMuslimWould rather not sayNoneOtherOther religion - Please explainSexual Orientation Heterosexual Lesbian / Gay Man / Bisexual Would rather not say Caring Responsibility People with caring responsibility Without caring responsibility (a family member would probably be considered to have a caring responsibility)And finally, have you contacted us before? Yes No Are you hearing impaired? Yes No Do you have a disability? Yes No Are you a member of the Dyspraxia Foundation? Yes No Is the enquiry about a child? Yes No Is the child? Male Female What is his/her age?Is the enquiry about an adult? Yes No Is the adult? Male Female What is his/her age?Does the child or adult have a diagnosis of dyspraxia?* Yes No Reason for the enquiry?*Please selectDiagnosisHealthEducationEmploymentOtherWhat level of education?Please selectPre-schoolPrimarySecondaryFurther EducationHigher EducationOther, please specify.How can we help you? (there is a maximum of 1000 characters) EmailThis field is for validation purposes and should be left unchanged.
