LGBT Foundation Sexual Health Advice Form

LGBT Foundation offers free, confidential spaces to talk about sexual health, sexual pleasure, STIs and HIV, contraception, and any other topics you may wish to discuss. If you are an LGBT+ person living in Greater Manchester and would like to speak to a member of the team fill out a form below.

If you are a professional filling out this form for a service user, please ensure that you have obtained the person’s consent for us to speak to them.

By completing this form and clicking 'submit' below, I 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.

My 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 1998 and the Health and Social Care Act 2001.

LGBT Foundation may also get information about me from certain other organisations or give information about me to them inlcuding: 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 or other healthcare professionals.

Your Name*

First NameLast Name

What is your preferred pronoun?

Other Pronoun - Please provide here

Your Birthdate*

Date

What is your preferred method of contact?*

PhoneEmail

Email*

example@example.com

Phone Number

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityCounty

Postal Code

What issue would you like to discuss?

Are you experiencing any symptoms of an STI?*

YesNoNot Sure

Have you had unprotected sex (no condom, no PrEP) in the last 72 hours?*

YesNoNot Sure

If yes, how long ago (approximately)?

What is the best time to contact you about your query? (days/dates/times)

Domestic abuse is an incident or multiple incidents of controlling, coercive, threatening, degrading or violent behaviour by a partner, ex-partner, or a family member. This can include, but is not limited to: coercive control, psychological, emotional, physical, sexual, financial or economic abuse, harassment and stalking.

Are you concerned you are experiencing domestic abuse and want to talk to someone about it?*

Yes - I am concerned I am experiencing domestic abuse and want to talk about itNo - I am NOT concerned I am experiencing domestic abuse or do not want to talk about it

LGBT Foundation - Speak to a Member of our Sexual Health Team

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