To contact us for Support Groups in South Africa Only
*Your E-mail Address:
*Your Name:
Suburb:
Town:
Nearest Large Town:
Nearest Large Town
Johannesburg
Pretoria
Cape Town
Durban
Port Elizabeth
Nelspruit
Bloemfontein
Kimberley
Province:
List Province
Gauteng
Kwa Zulu Natal
Northern Cape
Western Cape
Eastern Cape
Mpumalanga
North West
Limpopo
Free State
Are you a member of our on-line support group:
(Applicable to Parent/s, Family & Friends only)
Not Applicable
Yes
No
No But Please Mail Me Details
Support for:
If Support is for a SUFFERER complete all Fields Below :
Support For
Parent/s
Parents and Family Members
A Family Member
Friend
Sufferer
Gender of Sufferer:
Not Applicable
Male
Female
Age in Years:
Is the Sufferer presently seeing any of following:
Psychologist
Psychiatrist
Soc. Work
Other
None
Are you on Medication:
Not Applicable
Yes
No
Type of Disorder:
Not Applicable
Anorexia
Bulimia
Anorexia/Bulimia
Compulsive Overeating
To Return to our web site without completing the form Click on 'Home'
Complete all fields.
