Condom Postal Request "*" indicates required fields Are you under 25?*Select an OptionYesNoWe are sorry, this service is only available for people under 25. You can still pick up condoms in person at our clinics, or call 01903 285199 for any other queries.Do you live in West Sussex?*Select an OptionYesNoWhat age range are you in?*Select an OptionI am under 16I am 16 or 17I am 18 - 24Sorry, this service is only available to West Sussex residents. Please click here to find a service in your area.Demographic InformationDate of Birth*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Tell us your gender*Select an OptionMaleFemaleTrans maleTrans femaleOtherPrefer not to sayHow would you describe your sexuality?*Select an OptionHeterosexualGay/LesbianBisexualOtherPrefer not to sayHow would you describe your ethnicity*Select an OptionWhite BritishWhite IrishAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed backgroundIndian or British IndianPakistani or British PakistaniBangladeshi or British BangladeshiAny other Asian backgroundCaribbeanAfricanAny other Black backgroundChineseAny other ethnic groupPrefer not to answerDo you have a long term health problem or disability?*Select an OptionYesNoPrefer not to sayAre you in study, training or work?*Select an OptionYesNoIn the past three months have you?Been made to feel hurt, scared or controlled by a partner?*Select an OptionYesNoBeen forced or pressured to have sex you didn't want?*Select an OptionYesNoHad sex in exchange for money, gifts or drugs & alcohol?*Select an OptionYesNoFelt worried a partner may have exposed you to HIV or Hepatitis C?*Select an OptionYesNoUsed drugs before sex?*Select an OptionYesNoDrunk alcohol before sex?*Select an OptionYesNoSelf harmed or hurt yourself intentionally?*Select an OptionYesNoSent or received sexual pictures or messages (sexting)?*Select an OptionYesNoHad sex with someone more than four years older than you?*Select an OptionYesNoHad sex with someone who is in a position of trust (police, NHS, social services, counsellor or youth worker, care or support worker, religious or community leader)?*Select an OptionYesNoGone missing from home or care?*Select an OptionYesNoDo you see (or have been referred to) a social worker, counsellor or CAMHS worker?*Select an OptionYesNoCondom InformationTell us the size condoms you need?*Select an OptionRegular (Naturelle)TrimKing SizeNot sure (send mixture)Have you seen our condom demonstration video?*Select an OptionYesNoFurther QuestionsWe just need to ask a few more questions to check you understand the scheme. For some questions, you might want to tick more than one answer - that's fine.What is the Condom Distribution Scheme about?* A scheme offering condoms to people living in West Sussex, to help prevent STIs and pregnancy. I'm not sure Do you have to be having sex to use the Condom Distribution Scheme?* Yes No Don't know When can you start having sex?* Any age 13 or over 16 or over Don't know When is it ok to have sex with someone else?* When I want to When they want to When we both want to When we’re told to Are you sexually active (having sex with other people)?* Yes No Been told not to say Who do you talk to about sex and relationships?* Parents Other family member Friends Someone else (counsellor, support worker, social worker, teacher) Nobody Who would you go to if you had any worries about sex or relationships?* Parents Other family member Someone else (counsellor, support worker, social worker, teacher) Nobody Who knows you have requested condoms?* Parents Other family member Someone else (counsellor, support worker, social worker, teacher) Nobody Why are you requesting condoms?* I found out about it and thought it was a good idea Someone else told me to do it, I thought about it and was happy to Someone else told me to, I’m doing it to make them happy None of the above What would happen if you couldn’t get condoms from us?* I’d buy them somewhere I’d go to a sexual health clinic to get some I’d make sure person I have sex with has condoms I’d have sex without condoms I wouldn’t have sex Your Address DetailsFirst name*Surname*Mobile Number*Please do not use +44 for example: +4477771234567. Please use your 11 digit mobile number without spaces.Confirm Mobile number*Please do not use +44 for example: +4477771234567. Please use your 11 digit mobile number without spaces.Email* Enter Email Confirm Email 1st line of your address (including house number)*example: 1 Sparrow Road2nd line of your address*example: Upper StreetTown*example: HorshamCountyWest SussexPostcode*How would you like to receive your condoms?*Select an OptionPosted to my addressCollected from Crawley Sexual Health, 5th Floor, Crawley Hospital, W Green Dr, Crawley RH11 7DHCollected from a Chichester Sexual Health, St Richards Hospital, PO19 6SECollected from: Crawley Bewbush Family Hub Dorsten Square, Crawley, RH11 8XWCollected from: Crawley Broadfield Family Hub Creasys Drive, Crawley, RH11 9HJ Crawley Broadfield Family Hub Creasys Drive, Crawley, RH11 9HJCollected from: Chichester Family Hub St James' Road, Chichester, PO19 7ABCollected from: Worthing West Family Hub 81 Salvington Road, Durrington, Worthing, BN13 2JDCollected from: Worthing Central Family Hub The Library, Worthing Community Hub, Richmond Road, Worthing, BN11 1HDCollected from: Worthing East Family Hub Lyndhurst Methodist Church, Lyndhurst Road, Worthing, BN11 2DGCollected from: Mid Sussex Family Hub 51 Penn Crescent, Haywards Heath, RH16 3HPCollected from: Adur East Family Hub Middle Road, Shoreham-by-Sea, BN43 6GACollected from: Adur West Family Hub 42 North Road, Lancing, BN15 9ABCollected from: Arun East Family Hub Wickbourne Centre, Clun Road, Littlehampton, BN17 7DZCollected from: Horsham Family Hub The Needles Neighbourhood Centre, Three Acres, Horsham, RH12 1RSCollected from: Arun West Family Hub Laburnum Grove, Bersted, Bognor Regis, PO22 9HTCollected from: Chichester YPS (Young People's Shop), 29 South Street, Chichester PO19 1ELAdditional Information What do we do with this information?The information you have provided will enable us to send the condoms to you and register you on our systemThe information will be stored on our Sexual Health system and will NOT be available to any other health care provider, including your GP.We will NEVER share your information outside of our serviceWe will NEVER share your information with anyone other than you.The information will be used anonymously for mandatory statutory reportingWe are part of the NHS and are fully compliant with the NHS Act 2006, the Health and Social Care Act 2012, the Data Protection Act, and the Human Rights Act.More information can be found here https://www.england.nhs.uk/ig/about/ & https://www.nhsx.nhs.uk/information-governance/
