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* 1. Gender

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* 2. Age:

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* 3. Please tell us why you don’t currently use ICOS services [please tick all that apply]

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* 4. Which of ICOS services would be of most interest to you if you were able to attend them? [please tick all that apply]

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* 5. What do you feel are your greatest support needs at the present time? [Please tell us the 3 most important to you]

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* 6. Which of the following do you think are the main problems or issues in your community [please tick NO MORE THAN 3 options]

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* 7. If you would like to receive information about ICOS services, please provide an email address or telephone number below: 

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* 8. If you would like to take part in our £20 voucher prize draw, please leave your name, surname and contact details: 

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