lgbtreferral

Some of the data we collect from you at referral will be shared with the NHS as part of our funding agreement. This data includes your date of birth, postcode, gender and GP surgery but does NOT include your name or the reason you have made the referral.

To find out more information about how your data is used, or to opt-out from additional data tracking and research, please visit the website https://www.nhs.uk/your-nhs-data-matters/

I consent to the referral information given being shared

Today's Date

Your name

Please describe your gender identity:

What service(s) do you require?

11-16 LGBT+ Support Group 11-16 LGBT+ One to One Support 14-25 Trans Support Group 16-25 LGBT+ Support Group 16-25 LGBT+ One to One Support 11-25 Trans One to One Support

Date Of Birth

Use the format dd/mm/yyyy

Age

Must be between 11 and 25

How would you describe your sexual orientation?

How would you like to be known (pronoun)?

Your Address

Can we send letters to that address?

Yes No

Home Phone Number

Mobile Number

Can we contact you by phone at home?

Call Answerphone Message

Select all that apply

Can we contact you on this mobile number?

Call Answerphone Message Text Message

select all that apply

Your email address

Only complete this if we can contact you by email and you access emails regularly.

Do you have any mobility issues?

Yes No

If so, please briefly describe them

This is so we can arrange a suitable venue.

Do you have any communication issues?

Yes No

If so, please briefly describe them

This is so we can make sure we can communicate as effectively as possible with you.

Briefly tell us the reason you want to access our services and what you feel your needs are?

Please explain as fully as possible.