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  • LGBT Foundation Services - Self Referral Form

  • As a provider we are only commissioned to work in certain localities. Currently our services are open to community members living within the Greater Manchester or Liverpool areas including:

    • Manchester
    • Salford
    • Trafford
    • Bury
    • Bolton
    • Oldham
    • Tameside
    • Stockport
    • Rochdale
    • Wigan
    • Liverpool

    If you live in one of the localities listed above, our services are available via remote and in person including phone, and online platforms.

    We are also able to offer sexual health support, information, and advice for community members who are based within the City of Liverpool.

  • Do you live in one of the boroughs of Greater Manchester listed above or in Liverpool?*

  • Unfortunately, if you are outside of Greater Manchester or Liverpool we are currently unable to accept your referral to our wellbeing services. For more information on what services are available in your area, or to get brief emotional support and signposting, please contact our helpline by calling 0345 3 30 30 30 or emailing helpline@lgbt.foundation

  • Confidentiality

    We understand that confidentiality is important to our service users. The information that you share with us will be kept in the strictest confidence and in accordance with the Data Protection Act (2018). During the Intake and Assessment meeting, a member of the Services Team will explain to the service user the exceptional circumstances when confidential information will have to be shared, for example, if they or somebody else is at risk of significant harm or where there is a requirement in law in the case of serious criminal offences (in particular terrorism and money laundering). In such exceptional circumstances, we will try to get their consent before disclosing any information if that is possible and do our best to help them. For further info on our policy please contact us at 0345 3 30 30 30.

    Confidentiality Agreement

    By completing this form and signing the declaration below, you understand and agree to the following;

    LGBT Foundation will collect information about you and the care you receive, this includes your referral form, assessments notes, paperwork related to the services that you access and correspondence related to your care.

    LGBT Foundation will collect information about you and the care you receive. This includes your referral form, assessments notes, paperwork related to the services that you access and correspondence related to your care. Your information will either be stored in paper form and/or in electronic records. All data that is collected is subject to the strict rules of confidentiality laid down by Acts of Parliament, including the Data Protection Act 2018, the Health and Social Care Act 2001. LGBT Foundation may also get information about you from certain other organisations or give information about me to them; to make sure the information is accurate, prevent or detect crime or significant risk, and protect public funds. These organisations include local authorities, the police, and other healthcare professionals.

  • Who is this referral for*
  • Do you have consent from the person you are referring to make this referral?*

  • LGBT Foundation Services - Self Referral Form

    Please complete the form below to access our wide range of wellbeing services. Once you have submitted this form, we will invite you to an assessment. All of our services are free at the point of care and we are here if you need us.

  • What is your preferred pronoun?
  • Your Birthdate*
     - -

  • By providing your phone and email details, you are giving us consent to contact you via these methods - if this would cause any risk to yourself, please give an overview below.

  • Format: 07000000000.
  •  -
  • Preferred method of contact*
  • Should we be discrete when calling your phone number?
  • Is it okay to leave a voice message on your phone?
  • Is it okay to text your phone number?
  • Should we call you from withheld number?
  • Would us making a call to your number put you at any risk of harm?
  • Do you have a GP?*
  • We will need to have GP details in order to progress your referral. We know it can be difficult to find an inclusive GP surgery so we would like to know if you would like support to find the best GP for you?

  • You have requested support to find a GP that is best for you. We will share your details with our Pride in Practice team who will be in contact to support you through this process.

  • Do you wish us to contact your GP?

  • Demographics

  • Which of the following options describes how you think of yourself?
  • Is your gender identity the same as when given at birth?
  • Intersex is an umbrella term for biological variations in sex traits or reproductive anatomy. These can be present at birth or develop as part of puberty. Would you describe yourself as intersex?
  • Sexual Orientation - which of the options best describes you?
  • What is your religion or belief?
  • Ethnicity - which describes you best?*

  • We ask the next question to help us to meet the needs of all of our service users. We want to make getting support from us as easy as possible. You do not need to have a diagnosis or have been to see a doctor about a disability to tell us how we can help you.

  • Do you consider yourself to be disabled and/or neurodivergent?*
  • (Optional) Describe your disability or disabilities by selecting the options available
  • What is your employment status?
  • What is your parent/guardian status (Please select all that apply)*
  • Have you ever been in the armed forces?*
  • Are you living with HIV?
  • Are you a carer?*
  • (Socio-Economic Background) Which type of school did you attend for the most time between the ages of 11 -16?
  • (Socio-Economic Background) If you finished school after 1980, were you eligible for Free School Meals at any point during your school years?
  • (Socio-Economic Background) What is the highest level of qualification achieved by either of your parent(s) or guardian(s) by the time you were 18?
  • Are you currently an active volunteer with LGBT Foundation?*

  • Your Needs & Goals

  • Do you smoke?

  • This NHS page is where you can find your local service to help quitting or here https://www.nhs.uk/service-search/other-health-services/stop-smoking-support-services/ 

  • Our Services Explained

    • Talking Therapies - This service aims to provide the safe space needed to discuss emotions and identify strategies to maintain mental well-being. 
    • Domestic Abuse Support -  The service offers support for individuals who are facing risk or danger from a partner, ex-partner, or family member. 
    • Sexual Violence Support - Our Independent Sexual Violence Advisor (ISVA) can provide support and information to people who have experienced Sexual Violence and Abuse. 
    • Recovery Support - Our Recovery Programme is here to ensure that individuals find their own way to recovery and the relationship that they want with alcohol and drugs.   
  • Which region do you live in?
  • Greater Manchester - Which type(s) of support do you think would be useful? (Please select all that apply)*
  • Liverpool - Which type(s) of support do you think would be useful? (Please select all that apply)*

  • Domestic Abuse Questions

    If you are looking to access our domestic abuse support programme, please provide information for the service specific questions below

  • Sexual Violence Questions

    If you are looking to access our sexual violence support programme, please provide information for the service specific questions below

  • Domestic Abuse & Sexual Violence Questions

    If you are looking to access both our sexual violence and domestic abuse support programmes, please provide information for the service specific questions below
  • Was the sexual assault/violence recent or non-recent?

  • Please note: if the sexual assault was within 10 days you can contact a Sexual Assault Referral Centre for a forensic examination, emergency contraception, PEP and the first Hep B vaccination.

  • Approximate date of assault
     - -
  • Have you attended a Sexual Assault Referral Centre?
  • Have the police been involved?
  • If police have been involved, what is the status of the investigation?
  • Is the perpetrator known to you?
  • Perpetrator - Date of Birth
     - -
  • Does the perpetrator live at the same address as you?
  • Is there ongoing contact from the perpetrator?
  • Do you require an interpreter to support you accessing our services?*
  • What drew you to LGBT Foundation's services?
  • How did you hear of LGBT Foundation?
  • From time to time we like to follow up with service users to better understand the impact of our interventions, how they can be improved and where appropriate, help celebrate the work of team LGBT Foundation. Do you give permission for LGBT Foundation to contact you following your time in our services to ask about your experiences with us? (You can opt of this at any time by emailing optout@lgbt.foundation)*
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