Lancashire LGBT Self-Referral Form 24-25

The information which you give will be used in accordance with the General Data Protection Regulation and to enable Lancashire LGBT to compile statistics for our funders. We will not share any information that would identify you as an individual with anyone. The information will be kept securely, and will be kept no longer than necessary.

Please note, we are not an emergency service and your self-referral form will be picked up during our office hours 8.30am - 4.30pm Monday- Friday.
If you are seeking immediate support with your mental health please click on this link:
https://www.healthierlsc.co.uk/MentalHealthSupport

1. What is your name? *

2. What is your date of birth? *

	DD/MM/YYYY

3. What is your home address? *

4. Which local authority area do you live in? *

5. How do you describe your gender identity? *

Female
Male
Non-binary
Other (please specify):

6. Is your gender different to that which was assigned to you at birth? *

Yes
No
Prefer not to say

7. What are your pronouns?

8. How would you describe your sexual orientation? *

9. How would you describe your ethnicity? *

10. Do you have any religion or belief? *

Yes
No
Prefer not to say
If yes, please state:

11. Do you have any disabilities and/or describe yourself as disabled? *

Yes
No
Prefer not to say
If yes, please state:

12. Which services are you interested in ? *

Support Groups
1-2-1 Support
Counselling

What would you like to achieve from the support you require ?

13. Mental health assessment - (Scored 1 to 10) 1 = mostly negative 10 = mostly positive

How is your mental health and wellbeing currently ?
How confident do you feel in yourself ?
How is your self-esteem ?
How equipped do you feel to manage your current issues ?
How is your emotional support network ?

14. What is your phone number ? *

Phone number

Is there anything we should be aware of when making contact i.e. unsafe times to do so ?

15. What is your email address ? *

16. Please supply the name and phone number of your preferred contact person in case of an emergency. * *

Name	*
Phone number	*
The name they know you by