Which of the following services would you/ your child like to access? 11-25 LGBT+ Counselling Services LGBT+ Family Mediation 16-25 Support Service 11-16 LGBT+ Support/youth group 16-25 LGBT+ Support (Worksop Out on Wednesdays, WOW) To be completed by the young person or parent if the young person is under the age of 13 (referrals for young people under 13 will not be accepted without parent/carer information on the following page) Young Person’s General Information Full Name: How would you describe your sexual orientation: Preferred name to be used: Heterosexual/Straight (attracted to opposite gender) Gay Male (attracted to the same gender) Date of Birth: Age: Gay Female/Lesbian (attracted to the same gender) Bisexual (attracted to both genders) Address (including Post Code): Pansexual (attracted to any gender identity/orientation) Prefer not to say Prefer to self-describe as: Preferred Number: How do you describe your gender: Email Address (if applicable): ☐Female ☐Male Female Male ☐Trans ☐Trans Do you consent to being contacted by: (trans history) (trans history) ☐Female ☐Male Phone Text Email Post Gender Binary ☐ to self-describe as: ☐Prefer Do you consider yourself to have impairments, disabilities, long term illnesses, or health conditions? What would you like to be known as (preferred Yes No Pronoun) Him/Her/They/Other : If yes, please tell us about it: of the following best describes your nationality and ethnic origin? White Black or Black British Asian British British British ☐ Irish African Indian ☐ Other, please specify: Caribbean Bangladeshi ☐ Other, please specify: Pakistani please specify : Dual Heritage Chinese Other Ethnic Group White & Black British Chinese Prefer not to say White & Black Caribbean Other, please specify: Other, please specify: White & Black African White & Black Asian Other, please specify To be completed by for parent/carer or other significant adult (referrals for under 13 year olds will not be accepted without this information)
Which of the following services would you/ your child like to access? 11-25 LGBT+ Counselling Services LGBT+ Family Mediation 16-25 Support Service 11-16 LGBT+ Support/youth group 16-25 LGBT+ Support (Worksop Out on Wednesdays, WOW) To be completed by the young person or parent if the young person is under the age of 13 (referrals for young people under 13 will not be accepted without parent/carer information on the following page) Young Person’s General Information Full Name: Preferred name to be used: How would you describe your sexual orientation: Heterosexual/Straight (attracted to opposite gender) Gay Male (attracted to the same gender) Gay Female/Lesbian (attracted to the same gender) Bisexual (attracted to both genders) Pansexual (attracted to any gender identity/orientation) Prefer not to say Prefer to self-describe as: Date of Birth: Age: Address (including Post Code): Preferred Number: Email Address (if applicable): How do you describe your gender: ☐Female ☐Male ☐Trans Female ☐Trans Male ☐Female (trans history) ☐Male (trans history) ☐ Gender Binary ☐Prefer to self-describe as: What would you like to be known as (preferred Pronoun) Him/Her/They/Other : Do you consent to being contacted by: Phone Text Email Post Do you consider yourself to have impairments, disabilities, long term illnesses, or health conditions? Yes No If yes, please tell us about it: of the following best describes your nationality and ethnic origin? White Black or Black British Asian ☐ British ☐ Irish ☐ Other, please specify: British African Caribbean Other, please specify: British Indian Bangladeshi Pakistani please specify : Dual Heritage Chinese Other Ethnic Group White & Black British White & Black Caribbean White & Black African White & Black Asian Other, please specify Chinese Other, please specify: Prefer not to say Other, please specify: To be completed by for parent/carer or other significant adult (referrals for under 13 year olds will not be accepted without this information)
SelfRef.docx