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 you will need the service user with you to complete the mental health assessment part of the referral. 


Also, 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. What is your email address ? *


5. What is your phone 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. Date of Birth *


10. How would they describe their gender identity? *


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


12. Preferred pronouns *


13. How would they describe their sexual orientation? *


14. How do they describe their ethnicity? *


15. Do they have a religion or belief? *


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


17. What is their address including postcode ? *


18. What is their phone number ? *


19. What is their email address ?


20. Which services are they interested in ?  *


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


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


22. 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).


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


24. How did you find out about us? *


Please note, we are not an emergency service and this referral form will be picked up during our office hours
8.30am - 4.30pm Monday- Friday.
If the person you are supporting requires immediate support with their mental health please use the emergency contacts below. 

If  the person you are with, is at immediate risk of taking their own life go to your nearest A&E or call 999

Urgent (non emergency)
Mental Health Crisis Line - 08009530110

(Open 24 hours 7 days a week) 

Samaritans Helpline - 116 123

(Open 24 hours 7 days a week) 

Shout (text support) - 85258

(open 24 hours 7 days a week)