top of page
Donate
Exit
About
Services
Talkzone
LGBT+ Service Nottinghamshire
Peace of Mind
Contact
More
Use tab to navigate through the menu items.
LGBT+ Service
Self Referral
Please complete the referral form below.
Today's date
*
Legal name
*
Preferred/chosen name
*
How would you like to be known (pronouns)?
*
She/her
She/they
They/them
He/they
He/him
Other
Name and pronouns used at home or is/when contacting parents/carers
*
Please describe your sexual orientation
*
Heterosexual
Lesbian/Gay Woman
Gay
Bisexual
Pansexual
Asexual
Other
Please describe your gender identity
*
Male
Trans male
Female
Trans female
Non Binary
Gender Fluid
Questioning
Other
Is your gender identity the same as assigned at birth?
*
Yes
No
Prefer not to say
Your date of birth
*
Miesiąc
Age
*
How is best to describe your ethnicity/ethnic origin?
*
White/British
White/Irish
White/Eastern European
White/Other
White & Black/British
White & Black/Caribbean
White & Black/African
White & Asian
Other mixed background
Black/British
Black/African
Black/Caribbean
Black/Other
Asian/British
Asian/Indian
Asian/Bangladeshi
Asian/Pakistani
Asian/Other
Chinese
Chinese/Other
Other ethnicity/ethnic origin
Are you part of any religious group?
*
Christian
Catholic
Buddhist
Hindu
Jewish
Muslim
Sikh
No religion
Other
Home number
*
How do you wish to be contacted via your home number?
*
Call
Answerphone
Please do not contact me on my home number
Mobile number
*
How do you wish to be contacted on your mobile number?
*
Call
Answerphone
Text
Please do not contact me on my mobile number
Email
*
Do you consent to be contacted on this email?
*
Yes
No
Not applicable
Address
*
Do you consent to being contact by letter?
*
Yes
No
Not applicable
What is your GP surgery? (For monitoring purposes only)
*
Do you have any mobility issues?
*
Yes
No
Maybe
If so, please briefly describe
Do you have any communication issues?
*
Yes
No
Maybe
If so, please briefly describe
Reason for referral
Submit
bottom of page
