Project 93  Referral Form for Organisations:

SECTION 1: REFERRER DETAILS SECTION 1: REFERRER DETAILSSECTION 1: REFERRER DETAILS

Referrer's Name (Required)

Organisation / Agency (Required)

Referrer Email Address (Required)

Referrer Contact Number

SECTION 2: CLIENT DETAILS SECTION 2: CLIENT DETAILSSECTION 2: CLIENT DETAILS

Has the client consented to this referral? Has the client consented to this referral? Yes

Client's Full Name (Required)

Client's Date of Birth (DD/MM/YYYY) (Required)

Client's Preferred Pronouns

Client's Email Address (Required)

Client's Phone Number

Is it safe for us to contact the client directly? Is it safe for us to contact the client directly? Yes - Safe to contact and leave voicemail Yes - Safe to contact but NO voicemail No - Please contact the referrer only

SECTION 3: IDENTITY & HEALTH SECTION 3: IDENTITY & HEALTHSECTION 3: IDENTITY & HEALTH

Client's Sexuality Client's Sexuality Heterosexual / Straight Gay / Lesbian Bisexual Pansexual Queer Asexual Unsure / Questioning Prefer not to say Prefer to self-describe

Please specify:

Client's Gender Identity

Is the client's gender identity same as assigned at birth? Is the client's gender identity same as assigned at birth? Yes No Prefer not to say/Unsure

Is the client living with or affected by HIV? Is the client living with or affected by HIV? Living with HIV Affected by HIV (Family/Partner) No / Not Applicable

Diagnosis Context (Required) Diagnosis Context (Required) Previously Diagnosed (Long-term) New Diagnosis - Standard Testing New Diagnosis - A&E Opt-Out Testing Unknown

SECTION 4: REFERRAL CONTEXT SECTION 4: REFERRAL CONTEXTSECTION 4: REFERRAL CONTEXT

Services Required (Required) Services Required (Required) HIV Counselling HIV Support Groups HIV Testing LGBT Counselling LGBT Support Groups Trans Support (over 18s) Help for those supporting LGBT people

Reason for referral & any known risks