Our Room Referral Form

Our Room Referral Form
Who is this referral for?*

MeSomeone I support
Please tell us your name and connection to the client*

Referrer NameRelationship to client
Eligibility

Our Room is a charity that support male, trans and non-binary people who sex work. We can only work with people over 18.
Are you over 18?*

YesNo
Are you currently sex working OR have you sex worked in the past?*

YesNoUnsure
Do you consider yourself to be: male, trans, or non-binary?*

YesNoQuestioning
Our Room supports male, trans and non-binary adults who sex work. Unfortunately it looks like you don't meet our criteria.

Please see our Support Page for other services that may be able to support you. Or give us a call on 0161 834 1827 for advice. Our office is open 9am-5pm Tuesday-Thursday.
My Details:

(Please give the details of the person you are supporting)
Preferred Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Are you trans+?*
Is your gender different, or does it have more components, to the one assumed at birth?
Pronouns:
Example: He/Him, She/Her, They/Them. Please let us know if you use different pronouns in different contexts.
Do you consider yourself to have a disability?

YesNoNot surePrefer not to say
Is there anything we can do to make it easier or more comfortable for you to access appointments?
Is English your main language?*

YesNo
What is your main language?
Client contact details
Phone number
If you do not have access to a phone please leave blank
E-mail*
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Post code
When is best for us to contact you?

Tuesday morningsTuesday afternoonsWednesday morningsWednesday afternoonsThursday morningsThursday afternoons
How do you prefer to be contacted?

Phone callText messageWhatsAppEmail
Please tell us about any safety considerations around contact:
Are there any times when is would be unsafe for you to take a phone call? Should we use a different name/pronouns when contacting you?
Please use this space to tell us about the support you would like to get from Our Room
Please also tell us about anything you do NOT want to discuss in appointments
Feedback
How did you hear about us?*
Please tell us where you heard about us:
Should be Empty:

Our Room Referral Form

Eligibility

Client contact details

Feedback