famref

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

Date of Referral

YOUR Name

Your Home Phone Number

Your 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 Address

Can we send letters to that address?

Yes No

Relationship to child or young person (if applicable)

What service(s) are you referring to?

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

Child or young person's name

How would they describe their gender:

How would they describe their sexual orientation?

How would they like to be known (pronoun)?

Child or young person's Date Of Birth

Either use the popup calendar or just type the date in dd/mm/yyyy format

Age

Must be between 11 and 25

Young Person's Address

Can we send letters to that address?

Yes No

Home Phone Number

Mobile Number

Can we contact them by phone at home?

Call Answerphone Message

Select all that apply

Can we contact them on this mobile number?

Call Answerphone Message Text Message

select all that apply

Email address (only complete if the young person is aged over 13)

Only complete this if we can contact the client by email and they access emails regularly.

Can we send emails to that address?

Yes No

Does the young person have mobility issues?

Yes No Not known

If so, please briefly describe:

This helps us arrange a suitable venue

Does the young person have communication issues?

Yes No Not known

If so, please briefly describe:

Brief summary of support needs and reason for referral

Please explain as fully as possible.