Lancashire LGBT Third Party 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 only accept referrals for people aged 18 years or older

1. Date of referral *


2. Name of person making the referral *


3. Organisation name *


4. Email address *


5. Telephone number *


6. Do you have consent from the individual for this referral? *


7. Name (the name the person being referred would like us to use) *


8. Are they known by any other name? If so please let us know


9. Preferred pronouns *


10. Date of Birth *


11. Address including postcode *


12. Phone number *


13. OK to contact by phone/leave voicemail? *


14. OK to contact by text? *


15. Email address (if preferred method of contact)


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


16. How would they describe their gender identity? *


17. Do they identify as a different gender to the one on their original birth certificate? *


18. How would they describe their sexual orientation? *


19. How do they describe their ethnicity? *


20. Do they have a religion or belief? *


21. Do they have any disabilities or support needs? (knowing this will help us to support them in the best way) *


Please describe in as much detail as you can what support you have been giving this person and when that support began: *


22. Please describe the kind of support they are looking for from Lancashire LGBT: *


23. If they are requesting COUNSELLING, do they have a preference for a female or male counsellor?


24. If the request for support is in relation to gender identity, has there been a referral made to a gender
identity clinic (NHS or private)?


25. If yes, what clinic were they referred to & when was this referral made?


26. Do you have any concerns about this person’s own safety? (For example: self-harm, suicidal thoughts, drug or alcohol use, unsafe/risky sex, being abusive to others or others being abusive to them or those around them).


27. If yes, please describe


28. Are they being supported by any other relevant professional(s) at the moment? *


29. If yes, please provide their organisation, job role and contact details


30. Please give us the name of their GP and address of surgery *


31. Please provide the name of an emergency contact for the person being referred.
*Please note*- we will not contact other professionals, the GP or emergency contact without the client’s permission except in a situation where there are safeguarding concerns, for example, someone’s life is in immediate danger. *


32. Their relationship to the person being referred *


33. Their phone number *


34. Their address *


35. What name do they know the person being referred by? *


36. Please confirm that this client has given permission verbally for their personal details to be shared with Lancashire


37. How did you find out about us? *