LGBT Foundation Services - Service to Service Referral Form

LGBT Foundation are based in Manchester, UK, and aim to support to people across the country through a range of services including a national helpline. At the moment, some of our services including Talking Therapies (Counselling), Trans Advocacy and Substance Misuse have restricted eligibility, this means that we will not be able to accept referrals if you live outside of Greater Manchester.

Please complete the form below to refer someone to our wellbeing services. Once you have submitted this form, we will invite the service user to a remote assessment. All of our services are free at the point of care and we are here if you need us.

If you would like to refersomeone living outside of Greater Manchester, please contact us on 0345 3303030 or referrals@lgbt.foundation. If we are unable to accept your referral, we will be happy to suggest some alternative sources of support.

Confidentiality

Confidentiality is important to us and our service users. The information you share with us will be kept in the strictest confidence and in accordance with the Data Protection Act (2018). 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). Where possible, we will try to get their consent before disclosing any information and do our best to help them.

For further information on our policy please contact 0345 3 30 30 30.

Confirmation of consent

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

LGBT Foundation will collect information about you and the care you receive. This includes the client's referral form, assessments notes, paperwork related to the services that they access and correspondence related to their care.

Their information will be stored in either 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 2018and the Health and Social Care Act 2001.

To ensure accurate information, prevent or detect crime or significant risk; including the protection of public funds, LGBT Foundation may obtain information about service users from other organisations. These include local authorities, the polices and/or other healthcare professionals.

Name of Referrer (Required)
Name of Referring Organisation (Required)
Referrer Phone Number (Required)
Referrer Email Address (Required)
Have you undertaken a PHQ9 or other scaling assessment with the client? If so, please tell us their score
Have you undertaken a GAD7 or other scaling assessment with the client? If so, please tell us their scores
Did the client disclose active suicidal ideation or planning? (Required)
Please tell us about any risk identified during your assessment of the client – this should include details about suicidal ideation and previous suicide attempts, self-harm, domestic violence or other needs
Does the client have a diagnosis of an existing mental health condition? (Required)
Please tell us about the client’s mental health, including any medication they take and if anyone else is involved in their care (i.e. a community mental health team)
Is the client on a waiting list for any other service related to their mental health? (Required)
Service User First Name (Required)
Service User Last Name (Required)
What is service user's 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 client 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 client's 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 client 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 client's phone number(s)?
Client's preferred method of contact
Reason for referral (please provide details around the difficulties the service user would like support for and how long these difficulties have been present for)
If you have any additional information that you think would be helpful for us to know at this point, please provide them here (please include details of any specific needs that we need to be aware of, e.g. language, accessibility, disability)
Which of our services are they 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)
Accessed LGBT Foundation services before?
If they accessed our services before please give details what was accessed & when?
Tick here if you do NOT wish us to contact their GP
GP Surgery Name (Required)
Name of their GP (Person)
Describes how they think of themself?
Other gender (please provide details)
Is their gender identity the same as when given at birth?
Do they describe themsevles as intersex?
Sexual orientation - which of the options best describes them?
Sexual Orientation - Other
What is their religion or belief?
Religion - Other
Ethnicity - which describes them best? (Required)
Ethnicity - Other
Do they consider themselves to be disabled?
(Optional) Describe their disability or disabilities by selecting the options available
What is their employment status?
What is their 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 they ever been in the armed forces? (Required)
Are they a parent or guardian? (Required)
Are they living with HIV?
Are they a carer? (Required)
Are they currently an active volunteer with LGBT Foundation? (Required)