Lancashire LGBT Self-Referral Form 24-25

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:


1. What is your name? *


2. What is your date of birth? *


3. What is your home address? *


4. Which local authority area do you live in? *


5. How do you describe your gender identity? *


6. Is your gender different to that which was assigned to you at birth? *


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? *


11. Do you have any disabilities and/or describe yourself as disabled? *


12. Which services are you interested in ?  *


13. Mental health assessment - (Scored 1 to 10)  1 = mostly negative   10 = mostly positive 


14. What is your phone number ? *


15. What is your email address ?  *


16. Please supply the name and phone number of your preferred contact person in case of an emergency. * *


17. How did you find out about us? *