Does this teen have Yes If yes, please provide details: any access No requirements (for Don’t Know example, braille documents) Do they have any Yes If yes, please provide details: allergies? No Don’t Know Does this child/teen Yes If yes, please provide details: require an interpreter? No Don’t Know Teenagers equalities monitoring How would this child/teen Female describe their gender? Male Other (please specify): Don’t Know Is their current gender Yes different to the sex they were No assigned at birth? Don’t Know The 2010 Equality Act defines disability as physical or mental impairment ‘a which has a substantial and long term adverse [negative] effect on their ability to carry out normal day to day activities’ Based on the definition Physical Deaf/ hearing impaired above, do they consider Learning visually impaired themselves to have any Mental Health Other (please specify): kind of disability? (please tick any that apply) Don’t Know How would they describe their ethnicity? White British White and Black Caribbean White Irish White and Black African Gypsy or Irish Traveller White and Asian Any other White background Any other mixed/ multiple background Asian British British Asian Indian Black African Pakistani 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?
Does this teen have any access requirements (for example, braille documents) Yes No Don’t Know If yes, please provide details: Do they have any allergies? Yes No Don’t Know If yes, please provide details: Does this child/teen require an interpreter? Yes No Don’t Know If yes, please provide details: Teenagers equalities monitoring How would this child/teen describe their gender? Female Male Other (please specify): Don’t Know Is their current gender different to the sex they were assigned at birth? Yes No Don’t Know The 2010 Equality Act defines disability as ‘a physical or mental impairment which has a substantial and long term adverse [negative] effect on their ability to carry out normal day to day activities’ Based on the definition above, do they consider themselves to have any kind of disability? (please tick any that apply) Physical Learning Mental Health Deaf/ hearing impaired visually impaired Other (please specify): Don’t Know How would they describe their ethnicity? White British White Irish 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 British Black African Caribbean Any other Black background Other (please specify): Don’t Know Do they have a faith/ religion?
City-Teen-Advocate-Referral-Form.docx