Project 93 Self Referral Form:

SECTION 1: PERSONAL DETAILS

Full Name (Required)

Date of Birth (DD/MM/YYYY) (Required)

Preferred Pronouns

Email Address (Required)

Contact Number (Required)

Is it safe to leave a voicemail? (Required) Is it safe to leave a voicemail? (Required) Yes No

SECTION 2: IDENTITY & HEALTH

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

Please specify how you self-describe:

What is your gender identity?

Is your gender identity the same as assigned at birth? Is your gender identity the same as assigned at birth? Yes No Prefer not to say

Are you living with or affected by HIV? (Required) Are you living with or affected by HIV? (Required) Yes No Prefer not to say

SECTION 3: HOW CAN WE HELP?

Which services are you interested in? (Required) Which services are you interested in? (Required) LGBTQ+ Affirming Counselling HIV Specialist Counselling LGBTQ+ Social & Peer Support Groups HIV Support & Social Groups Trans Mentor Scheme HIV Testing & Prevention Advice Support for Families, Partners & Allies

SECTION 4: OUTREACH

How did you hear about Project 93? How did you hear about Project 93? Social Media (Facebook, Instagram, TikTok) Healthcare Professional (GP, NHS Open Clinic) Educational Institution (School, College, University) Local Event (Stoke Pride, Freshers' Fair) A "Proud Space" Sticker Word of Mouth (Friend or Colleague) Search Engine (Google/Bing)