British ☐ White and Black Caribbean ☐ ☐ ☐ Irish White and Black African White Gypsy or Irish Traveler ☐ White and Asian ☐ Any other mixed/ multiple Any other White background ☐ background ☐ Asian British ☐ Black British ☐ Asian Indian ☐ Black African ☐ Asian Pakistani ☐ Black Caribbean ☐ Asian Bangladeshi ☐ Any other Black background ☐ Any other Asian background ☐ Other (please specify): Chinese☐ _________________________ Arab ☐ Don’t Know ☐ Do they have a faith/ religion? No religion Muslim ☐ ☐ Bahai ☐ Buddhist Shinto ☐ ☐ Christian ☐ Hindu ☐ Sikh ☐ Jewish ☐ Jain Zoroastrian ☐ ☐ Other: ______________________________ Don’t Know ☐ What is their relationship status? Civil partnership ☐ (tick one option) Married ☐ Divorced ☐ Separated ☐ Cohabiting but not married/ CP ☐ In a relationship (not cohabiting) ☐ Widowed ☐ Single ☐ What is their sexual orientation? ☐ Heterosexual/ straight (tick one option) Gay woman/ Lesbian ☐ Gay man ☐ Bisexual ☐ Something else: _________________ Don’t Know ☐
British ☐ Irish ☐ White Gypsy or Irish Traveler ☐ Any other White background ☐ Asian British ☐ Asian Indian ☐ Asian Pakistani ☐ Asian Bangladeshi ☐ Any other Asian background ☐ Chinese☐ Arab ☐ White and Black Caribbean ☐ White and Black African ☐ White and Asian ☐ Any other mixed/ multiple background ☐ Black British ☐ Black African ☐ Black Caribbean ☐ Any other Black background ☐ Other (please specify): _________________________ Don’t Know ☐ Do they have a faith/ religion? No religion ☐ Bahai ☐ Buddhist ☐ Christian ☐ Hindu ☐ Jewish ☐ Jain ☐ Muslim ☐ Shinto ☐ Sikh ☐ Zoroastrian ☐ Other: ______________________________ Don’t Know ☐ What is their relationship status? (tick one option) Civil partnership ☐ Married ☐ Divorced ☐ Separated ☐ Cohabiting but not married/ CP ☐ In a relationship (not cohabiting) ☐ Widowed ☐ Single ☐ What is their sexual orientation? (tick one option) Heterosexual/ straight ☐ Gay woman/ Lesbian ☐ Gay man ☐ Bisexual ☐ Something else: _________________ Don’t Know ☐
PDVG-KABWWA-Referral.docx