LGBT Foundation Services - Service to Service Referral Form

Please complete the form below to refer an individual to our wide range of wellbeing services. Once you have submitted this form, we will invite the service user 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, 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 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 professionals.

Name of Referrer (Required)
Name of Referring Organisation (Required)
Referrer Phone Number (Required)
Referrer Email Address (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
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)
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 client is 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 you have completed a Risk Identification Checklist (RIC) with the client, please provide the score here
If children are involved in client's current situation, please provide brief detials in this box including: name of child(ren), date(s) of birth, their relationship to client and the perpetrator.
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)
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)