Today's date

Full legal name

Preferred/chosen name

If different form above. When contacting you, we will use your preferred name. If you do not wish to be contacted by your preferred name, please leave blank and we will discuss during your assessment appointment.

Is your gender identity the same as assigned at birth?

Yes

No

Prefer not to say

Your date of birth

Day

Month

Year

Referrals can only be accepted if you are aged 11-25 or a parent/carer of a LGBT+ child or young person.

Multi-line address

Country/Region

Address

City

Zip / Postal code

GP Information

Name of GP practice

Address of GP practice

Please include postcode.

Phone number of GP practice

Details of any other services, organisations or professionals you are working with, or on a waiting list for.

Please provide the name of the organisation, the address and the reason for support.

Emergency contact information

Name of emergency contact

This should be a trusted adult, preferably someone who has responsibility for you such as a parent or carer. We will not contact this person before your assessment where emergency contact procedures will be explained to you.

Relationship to you

Does this person live at the same address as you?

Yes

No

If no, please specify

Phone number of emergency contact

Does this person know you are referring to LGBT+ Service Nottinghamshire?

Yes

No

Do we have permission to contact your emergency contact?

Yes

No

If you are under 16 years of age, we cannot process your referral without consent to contact someone in cases of an emergency. In safeguarding situations, if you are under the age of 16 we will be required to contact your parents or carers.

How can we best contact you

Phone

Can we call you on this number?

Yes

No

Can we leave a voicemail

Yes

No

Can we send a text message

Yes

No

Email

Do you consent to be contacted on this email?

Yes

No

Reason for referral:

What is the main reason for your referral?

Please tick all that apply.

Please tell us why you are making the referral

What type of support do you require?

Please tick all that apply.

1-1 support is delivered by our LGBT+ project workers who are able to provide practical and emotional support. LGBT+ specialist counselling is one-to-one therapy delivered by our counsellors.

Do you have any disabilities, health conditions or access needs that it would be helpful to tell us about?

We want to make sure we do our best to accommodate these.

I understand that I will be contacted by LGBT+ Service Nottinghamshire and that failure to respond may result in me being discharged from the service.

I understand that my data will be stored electronically and securely in line with LGBT+ Service Nottinghamshire's GDPR procedures.

I understand it is my responsibility to update LGBT+ Service Nottinghamshire with any changes to my personal details, such as address and phone number.

Thank you for submitting your referral to LGBT+ Service Nottinghamshire. We aim to be in touch within 5 working days. If you have any questions or queries, please call the office on 01909 479191.