Do you have any disabilities? If Yes, please detail below □ □ □ □ Mobility Visual Impairment Hearing Impairment Autistic Spectrum Condition □ □ □ Mental Health Learning Disability Progressive disability/Chronic illness (e.g. MS, cancer) □ □ Other – please state: I do not wish to disclose 6c. How would you describe your ethnic origin? □ □ □Other White: British Irish □ □ Mixed: White & Black Caribbean White & Black African □ □ White & Asian Other □ □ □ Asian or Asian British: Indian Pakistani Bangladeshi □ □ Chinese Other □ □ □ Black or Black British: Caribbean African Other □ □ Other ethnic group: Arab Other ethnic group □ Gypsy, Romany, Irish Traveller □ I do not wish to answer 6d. How would you describe your sexual orientation? Please tick as appropriate. (optional – you do not have to answer this question) □ □ □ Heterosexual / straight Gay man Lesbian □ □ □ Bisexual Other I do not wish to answer 6e. Culture / Religion □ □ Do you have any cultural or faith/religious requirements? Yes No If Yes, please give details: Section 7 – Information
Do you have any disabilities? If Yes, please detail below □ Mobility □ Visual Impairment □ Hearing Impairment □ Autistic Spectrum Condition □ Mental Health □ Learning Disability □ Progressive disability/Chronic illness (e.g. MS, cancer) □ Other – please state: □ I do not wish to disclose 6c. How would you describe your ethnic origin? White: □ British □ Irish □Other Mixed: □ White & Black Caribbean □ White & Black African □ White & Asian □ Other Asian or Asian British: □ Indian □ Pakistani □ Bangladeshi □ Chinese □ Other Black or Black British: □ Caribbean □ African □ Other Other ethnic group: □ Arab □ Other ethnic group Gypsy, Romany, Irish Traveller □ I do not wish to answer □ 6d. How would you describe your sexual orientation? Please tick as appropriate. (optional – you do not have to answer this question) □ Heterosexual / straight □ Gay man □ Lesbian □ Bisexual □ Other □ I do not wish to answer 6e. Culture / Religion Do you have any cultural or faith/religious requirements? □ Yes □ No If Yes, please give details: Section 7 – Information
Housing-Support-Oxon-Referral-Form-Jan-2017.docx