Ethnic (Please tick one box only): White Asian or Asian British British (including Scottish and Welsh) Indian Indian British Irish Pakistani Pakistani British Gypsy Bangladeshi Bangladeshi British Travellers Other White background (please specify) Other Asian background (please specify) ………………………………………………. ……………………………………………… Mixed Black or Black British White & Black Caribbean Caribbean Caribbean British White & Black African African African British White & Asian Other mixed background (please specify) Other Black background (please specify) Chinese Japanese Other (please specify) Gender Physical Disability Mental Disability Learning Male Female Difficulty Transgender Do not Yes No Yes No Yes No wish to disclose First language Sexual Orientation English Lesbian Bi Sexual (please specify) Gay Do not wish to disclose … Translator required Heterosexual (straight) Age Religion 16 -17 18 25 Christian Jewish – 26 35 36 - 45 Muslim Buddhist – 46 55 56 - 65 Hindu Sikh – 66 + Atheist No Religion Do not wish to disclose
Ethnic (Please tick one box only): White Asian or Asian British British (including Scottish and Welsh) Indian Indian British Irish Pakistani Pakistani British Gypsy Bangladeshi Bangladeshi British Travellers Other White background (please specify) Other Asian background (please specify) ………………………………………………. ……………………………………………… Mixed Black or Black British White & Black Caribbean Caribbean Caribbean British White & Black African African African British White & Asian Other mixed background (please specify) Other Black background (please specify) Chinese Japanese Other (please specify) Gender Male Female Transgender Do not wish to disclose Physical Disability Yes No Mental Disability Yes No Learning Difficulty Yes No First language English (please specify) … Translator required Sexual Orientation Lesbian Bi Sexual Gay Do not wish to disclose Heterosexual (straight) Age 16 -17 18 – 25 26 – 35 36 - 45 46 – 55 56 - 65 66 + Religion Christian Jewish Muslim Buddhist Hindu Sikh Atheist No Religion Do not wish to disclose
cotswoldscbsreferral.docx