Welcome to MYPAS LGBT+ Services!
We aim to make our services a safe and supportive space for young people who identify as LGBT+. All of our services are friendly, free and confidential. This means that we won’t tell anyone that you are attending the service without your permission unless we are concerned about your safety or the safety of others. We look forward to working with you! From the MYPAS LGBT+ Team
Registration Form
Please note we use this information to update our client records and your information is strictly confidential. For details of our Privacy Policy, please follow this link: https://www.mypas.co.uk/mypas-privacy-policy/
Date form completed
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Name (this is visible to all MYPAS staff members)
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First Name
Last Name
Is there a name you're using at the social group that is different from above?
Birth Date
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Home Address
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Street Address Line 2
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Phone number
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Email
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example@example.com
Phone Number
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Area Code
Phone Number
Services you are accessing/ would like to access
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LGBT+ Social Groups
LGBT+ One-To-One Service
LGBT+ Educational/ School Group Program
Counselling (school or community)
Art therapy (school or community)
Drug and alcohol support
If you can, please tell us why you are contacting MYPAS:
Does the young person know about and consent to this referral?
Yes
No
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Next
Emergency Contact 1
Please fill out the details of the person you would like us to contact in case an emergency
Name
*
First Name
Last Name
Relationship to you
*
Phone number of emergency contact
*
Phone Number
-
Area Code
Phone Number
Do we have your permission to contact this person in case of an emergency?
*
Yes
Emergency Contact 2
Please fill out the details of a second person you would like us to contact in case an emergency. If you only have one emergency contact, please leave this section blank.
Name
First Name
Last Name
Relationship to you
Phone number of emergency contact
Phone Number
-
Area Code
Phone Number
Do we have your permission to contact this person in case of an emergency?
*
Yes
Health Information
Do you have any allergies, disability or access needs that we should know about?
Submit
Should be Empty: