Lancashire LGBT Self-Referral Form 23-24

The information which you give will be used in accordance with the General Data Protection Regulation. We will not share any information that would identify anyone unless there are safeguarding concerns. 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. Please describe in your own words what it is you need help with from Lancashire LGBT. *

13. How would you prefer us to contact you? PLEASE REMEMBER TO LEAVE YOUR PHONE NUMBER OR EMAIL ADDRESS IN THE BOX BELOW! *

Call
Text
Email

Please provide your preferred contact details here and anything we should be aware of when making contact i.e. unsafe times to do so.

14. How did you find out about us? *

What happens next? One of the Lancashire LGBT team will be in contact with you within 5 working days using your preferred contact method.
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.