LGBT Foundation Services - Self Referral Form

Please complete the form below to access our wide range of wellbeing services. Once you have submitted this form, we will invite you to our building for an assessment. All of our services are free at the point of care and we are here if you need us.

Confidentiality

We understand that confidentiality is important to our service users. The information that you share with us will be kept in the strictest confidence and in accordance with the Data Protection Act (1998). During the Intake and Assessment meeting, a member of the Services Team will explain to the service user the exceptional circumstances when confidential information will have to be shared, for example, if they or somebody else is at risk of significant harm or where there is a requirement in law in the case of serious criminal offences (in particular terrorism and money laundering). In such exceptional circumstances, we will try to get their consent before disclosing any information if that is possible and do our best to help them. For further info on our policy please contact us at 0345 3 30 30 30.

By completing this form and clicking 'submit' below, I understand and agree to the following;

LGBT Foundation will collect information about you and the care you receive, this includes your referral form, assessments notes, paperwork related to the services that you access and correspondence related to your care.

My information will either be stored in paper form and/or in electronic records. All data that is collected is subject to the strict rules of confidentiality laid down by Acts of Parliament, including the Data Protection Act 1998, the Health and Social Care Act 2001.

LGBT Foundation may also get information about me from certain other organisations or give information about me to them: to make sure the information is accurate: prevent or detect crime or significant risk: and protect public funds. These organisations include local authorities, the police and or other healthcare professional

First Name (Required)
Last Name (Required)
I am willing and able to access services remotely – by phone or video platforms (i.e. Zoom or WhatsApp)

We’re sorry but at the moment we are only able to offer remote services and cannot accept referrals for face to face delivery. As lockdown restrictions alter, and we are able to again offer face to face services, we will advertise this on our website and social media channels. In the meantime, if you feel you are reaching crisis or need information about services providing face to face support at this time, please contact our Helpline on 0345 3303030 or Helpline@lgbt.foundation for signposting

What is you preferred pronoun?
Birthdate (DD/MM/YYYY) (Required)
Street
Town/City
Postcode (Required)
Is it okay for us to write to this address?
Email
Is it okay for us to write to this email address?
Phone (Required)
Mobile
Is it okay to leave a message? (Please select all that apply. If you are using a computer/laptop, hold ctrl and left click to select all the relevant options)
Is it okay to text your mobile number? (Please select all that apply. If you are using a computer/laptop, hold ctrl and left click to select all the relevant options)
Should we call you from witheld number? (Please select all that apply. If you are using a computer/laptop, hold ctrl and left click to select all the relevant options)
Should we be discrete when calling your phone number(s)?
What is your preferred method of contact?
Which of our services are you particularly interested in? (Please select all that apply. If you are using a computer/laptop, hold ctrl and left click to select all the relevant options)
What difficulties do you have that you would like support with? (if seeking support for domestic abuse, please give brief outline of your current situation, including the most recent incidents of abuse and your housing situation)
What do you hope will be different as a result of using our services? (Required)
If you are looking to access our domestic abuse support programme, please provide information in for the service specific questions below:

Perpetrator - Name
Perpetrator - Date of Birth
Perpetrator - Gender
Perpetrator - Relationship to Client
If children are involved in your current situation, please provide brief detials in this box including: name of child(ren), date(s) of birth, their relationship to you and the perpetrator
Are there any specific needs that we need to be aware of?
Have you accessed LGBT Foundation services before?
If you accessed our services before please give details what was accessed & when?
Tick here if you do NOT wish us to contact your GP
GP Surgery Name (Required)
Name of your GP (Person)
Which days and times would be best for you to access our services? (Required)
Describes how you think of yourself?
Other gender (please provide details)
Is your gender identity the same as when given at birth?
Do you describe yourself as intersex?
Sexual orientation - which of the options best describes you?
Sexual Orientation - Other
What is your religion or belief?
Religion - Other
Ethnicity - which describes you best? (Required)
Ethnicity - Other
Do you consider yourself to be disabled?
(Optional) Describe your disability or disabilities by selecting the options available
What is your employment status
What is your relationship status (Please select all that apply. If you are using a computer/laptop, hold ctrl and left click to select all the relevant options)
Have you ever been in the armed forces? (Required)
Are you a parent or guardian? (Required)
Are you living with HIV?
Are you a carer? (Required)
Are you currently an active volunteer with LGBT Foundation? (Required)
How did you hear of LGBT Foundation?