Spectra Trans Health Advocacy Application Form

Please verify that you are human
Have you used any of these Spectra services in the past?

Other
Was this within the past 3 months
- First Name
- Last Name
- Preferred Name
- Your Pronouns
  
  Other
- Date of Birth
  
  DayMonthYear
  Date
- Your borough of residence
  Please note that this service is for people lives in London only.
- Ethnic Origin
  
  Other
- Which country were you born in?
- Are you a refugee or an asylum seeker?
- Gender Identity
  
  Other
- Is your current gender identity same as you were assigned at birth?
- Sexual Orientation
  
  Other
- Any disability/neurodiversity?
- Please provide more details if so.
- What access or language support do you need to access this service?
- Have you been referred to a gender clinic?
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (+44) 000-0000-0000.
- In order to arrange appointments we will contact you by phone and email. If you prefer not to receive communication by any of these methods, please change the appropriate boxes.
- Phone call
- Text
- Voicemail
- Email
- Address
- Other communication preferences
- GP Name
- GP Contact Details
- Is your GP aware of your gender identity?
- Name you use with your GP
  If different from above.
- Emergency contact name
- Emergency contact phone number
  Please enter a valid phone number.Format: (+44) 000-0000-0000.
- Emergency contact email
  example@example.com
- Relationship to you
- If you are a professional referring on behalf of a service user, please leave your details here
- How did you find us?
- Please rate your level of need
  
  1
  
  2
  
  3
  
  4
  
  5
  
  6
  
  7
  
  8
  
  9
  
  10
  
  1 is Low, 10 is High - Urgent
- What has led you to apply for this service?
- How do you hope advocacy might help?
- Are you currently waiting for any service elsewhere?
- Are you interested with any other Spectra services?
- Internal share
- General healthcare
- Hormone access
- Medical referral
- Moving prescription to UK
- Blood tests
- Surgery
- Complaint
- Eating Disorder
- Medical records
- Domestic Violence
- Isolation
- Self esteem
- Chronic pain
- Mental health
- Disability access
- Anything else?
- Please indicate your preferable time and day(s) of the week for advocacy appointment.
  For example: 1pm-7pm, Monday to Friday; 4pm-7pm, Wednesday
- Preferred Platforms*
- Do you have any important dates for appointments or deadlines?
- I agree to Spectra's Trans Health Advocacy Service acting on my behalf
- I agree to Spectra receiving and keeping sensitive personal information concerning me
- I understand that Spectra's Trans Health Advocacy Service will share with me any information received
- I have read and understand Spectra's Trans Health Advocacy Service Privacy & Accessibility Policies
- I would like to subscribe to your newsletter
- I agree with Spectra's privacy policy
- The name of the Data Processer is: Joel Robinson, Spectra CEO
  
  You can find Spectra's privacy policy here.
- Should be Empty: