lgbtproreferral

Date of Referral

Your Name

Your Phone Number

Your Email

Relationship to child or young person (if applicable)

Referring Organisation

What service(s) do you require?

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

Child or young person's name

How would they describe their gender:

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

How would they describe their sexual orientation?

How would they like to be known (pronoun)?

Client'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 this if we can contact the client by email and they access emails regularly.

Does the client have mobility issues?

Yes No Not known

If so, please briefly describe:

This helps us arrange a suitable venue

Does the client have communication issues?

Yes No Not known

If so, please briefly describe:

Reason For Referral

Please explain as fully as possible.

Please outline your involvement

Please explain as fully as possible.

Risk Assessment:

Would you consider it safe to visit this young person/family at home?

Yes No

Please give details

Does the young person/family present as a risk to staff, the public other service users or themselves?

Yes No

Please give details

Is there any further information that we need to be aware of? (e.g. mental health issues, self-harm, suicidal ideation, etc)?

Yes No

Please give details

Do they have any involvement with any other agencies (e.g. social services, CAMHS, voluntary sector, support groups, etc)?

Yes No

Please give details