Project 93 Parent or Carer Referral Form for a Child:

SECTION 1: CHILD'S DETAILS

Child's Full Name (Required)

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

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

Please specify:

Child's Gender Identity

Preferred Pronouns

SECTION 2: PARENT DETAILS

Your Full Name (Required)

Relationship to Child (Required)

Your Email Address (Required)

Your Contact Number (Required)

Is it safe to leave a voicemail? (Required) Is it safe to leave a voicemail? (Required) Yes No Prefer not to say

SECTION 3: HEALTH & SERVICES

Is the child/family living with or affected by HIV? (Required) Is the child/family living with or affected by HIV? (Required) Yes No

What brings you to Project 93?

Services you are interested in (Required) Services you are interested in (Required) LGBTQ+ Affirming Counselling Transgender Support HIV Support & Counselling HIV Testing & Prevention Advice Support For Parents

How did you hear about Project 93? How did you hear about Project 93? Social Media Healthcare Professional (GP/Clinic) School, College or University Local Event (Pride, Freshers) Word of Mouth Search Engine