Family Referral Form – Barnardo's Positive Identities Service

Name(Required)

First Name Last Name

Address(Required)

House No./Name Street City County Postcode

One of our team will be in touch about the support we can offer

Phone Number(Required)

Email Address(Required)

Please include everyone you think plays an important support role for your child/children

Who is in your family?(Required)

Name

Relationship to you

Age

Me and/or my family would like guidance in supporting my child/family member around their sexuality (who you are attracted to)

Me and/or my family would like guidance in supporting my child/family member around their gender identity (how you feel about your gender)

Me and/or my family are experiencing bullying¬ or discrimination because of our gender identity and/or sexuality

I would like my family to be more understanding/supportive of my identity

Something else (please let us know in the box below)

I would like help with ‘coming out’ (telling people about your identity) to friends or family

I would like help around my mental health

Something else (please let us know in the box below)

Please let us know in more detail your situation and what you would like help & support with: