Lancashire LGBT Third Party Referral Form 24-25

1. Date of referral *

	DD/MM/YYYY

2. Name of person making the referral *

3. Do you have consent from the individual for this referral and for their information to be shared with Lancashire LGBT? *

4. Your organisation name *

5. What is your email address ? *

6. What is your phone number ? *

7. Name of person being referred *

8. Are they known by any other name? If so please let us know

9. Date of Birth *

	DD/MM/YYYY

10. How would they describe their gender identity? *

Female
Male
Non-binary
Other (please specify):

11. Do they identify as a different gender to the one on their original birth certificate? *

Yes
No
Prefer not to say

12. Preferred pronouns *

He/Him
She/Her
They/Them
Other (please specify):

13. How would they describe their sexual orientation? *

14. How do they describe their ethnicity? *

15. Do they have a religion or belief? *

Yes
No
Prefer not to say

If yes, please state

16. Do they have any disabilities or support needs? (knowing this will help us to support them in the best way) *

If yes, please state

17. What is their address including postcode ? *

18. What is their phone number ? *

Phone number

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

19. What is their email address ?

20. Which services are they interested in ? *

Support Groups
1-2-1 Support
Counselling

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

Please describe in as much detail as you can what support you have been giving this person and when that support began: *

21. 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 ?

22. Do you have any concerns about this person’s own safety? (For example: self-harm, suicidal thoughts, drug or alcohol use, unsafe/risky sex, being abusive to others or others being abusive to them or those around them).
*

If yes, please describe

23. Please supply the name and phone number of a preferred contact person in case of an emergency.

Name
Phone number
The name they know you by

24. How did you find out about us? *

Please note, we are not an emergency service and this referral form will be picked up during our office hours
8.30am - 4.30pm Monday- Friday.
If the person you are supporting requires immediate support with their mental health please use the emergency contacts below.

Emergency
If the person you are with, is at immediate risk of taking their own life go to your nearest A&E or call 999

Urgent (non emergency)
Mental Health Crisis Line - 08009530110

(Open 24 hours 7 days a week)

Samaritans Helpline - 116 123