Today's date

Are you a parent/carer or a professional?

Parent / Carer

Professional

If Professional:

Your full name:

Role and relationship to young person:

Job title:

Organisation:

Contact number:

Email address:

Consent

Is the young person aware you are making this referral?

Yes

No

Are the young person's parents or carers aware of this referral and have they consented to it?

Yes

No

If no, please explain further.

Young Person's Details

Child's/young person's legal name

Child's/young person's preferred/chosen name

Their date of birth

Dzień

Miesiąc

Rok

Please note we can only accept referrals if you are aged 11-25 or if you are the parent or carer of a LGBT+ young person.

Multi-line address

Kraj/region

Adres

Miejscowość

Kod pocztowy

Is their gender identity the same as it was assigned at birth?

Yes

No

Prefer not to say

GP Information

Name of GP practice:

Address of GP practice

Phone number of GP practice

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

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

Parent/carer information

Parent/carer's name:

Parent/carer's address

Same as the young person

Different to above

If different from the young person, please specify:

Contact details

Preferred person to contact regarding this referral?

Parent / Carer

Young Person

If parent and/or carer:

Phone number:

Is it ok to:

Leave an answerphone message

Send a text message

Call

Please do not leave any messages

If young person:

Phone number:

Email

Reason for referral:

What is the reason support is required?

Please tick all that apply.

Please tell us more about why you are making the referral:

What type of support is required?

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+ specialsit counselling and family mediation is therapeutic support delivered by our counsellors.