Young Person Referral Form What is your name and date of birth?Name(Required) First Name Last Name Date of Birth(Required) DD slash MM slash YYYY What is your address?Address(Required) House No./Name Street City County Postcode How can we contact you?Phone Number(Required)Email Address(Required) How can we help you?Untitled(Required) Exploring sexuality (who you are attracted to) Exploring gender identity (how you feel about your gender) I am experiencing bullying¬ or discrimination I would like my family to be more accepting of my identity I struggle with confidence 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 kind of support you are looking for: Δ
