First name
* Required
Surname
* Required
Preferred name (if any)
How do you currently define your gender?
Preferred Personal Pronouns
Ethnicity
Please select White British White Irish White Gypsy or Irish Traveller White Asian White other Black/White Caribbean Black/White African Indian Pakistani Bangladeshi Chinese African Caribbean Other
Full address
* Required
Postcode
* Required
Preferred contact number/email address
* Required
Date of Birth
* Required
First language
* Required
Do you require an interpreter?
How can we contact you?
* Required
Please can you explain briefly why you are referring yourself to this service
* Required
How are you feeling at the moment?
Have you ever been diagnosed with a mental health problem?
* Required
Do you consider yourself to be at risk from anyone else?
* Required
Have you ever harmed yourself deliberately, or considered harming yourself?
* Required
What support do you have available to you?
* Required
What support do you think might be helpful to you?
* Required
Do you have any form of disability that we might need to take into account?
* Required
Have you been diagnosed with an autistic spectrum condition?
* Required
Have you been referred to a Gender Identity Clinic? If so, which one?
* Required
Have you had any treatment in relation to your gender identity? (e.g. hormones)
* Required
Do we have your permission to share this information with your GP
Please advise of your GP details
* Required
If so, in which of the following ways
Please select Phone Email In writing to your address - We would like to send an opt in letter for the service to your home address. Therefore please select this option. If you do not want any correspondence to your address, please select another form of contact
In which of the following ways are you happy for us to contact you?
* Required** None Phone Email Text/SMS
What is your email address?
* Required
We will only send an opt in once your referral has been reviewed by a counsellor
Consent for storing submitted data
