Does this client require an Yes If yes, please provide details: interpreter? No Don’t Know Client equalities monitoring How would this client describe their Female gender? Male In another way:_________________ Is their current gender different to the Yes sex they were assigned at birth? No Don’t know Do they consider themselves to have Physical any kind of disability? Learning (please tick any that apply) Mental Health Deaf/ hearing impaired Blind/ visually impaired Something else:_________________ Don’t Know How would they describe their ethnicity? White British White and Black Caribbean Irish White and Black African White Gypsy or Irish Traveller White and Asian Any other White background Any other mixed/ multiple background Asian British Black British Asian Indian Black African 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 Shinto Buddhist Sikh Christian Zoroastrian Hindu Jewish ______________________________ Jain 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
Does this client require an interpreter? Yes No Don’t Know If yes, please provide details: Client equalities monitoring How would this client describe their gender? Female Male In another way:_________________ Is their current gender different to the sex they were assigned at birth? Yes No Don’t know Do they consider themselves to have any kind of disability? (please tick any that apply) Physical Learning Mental Health Deaf/ hearing impaired Blind/ visually impaired Something else:_________________ Don’t Know How would they describe their ethnicity? White British Irish White Gypsy or Irish Traveller Any other White background Asian British Asian Indian 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 ______________________________ 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
County-Men-DVA-Equation-Referral-Form.docx