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Youth Referral or HIV Support Referral
Person Referring:
Referrers Name*
Referrers Phone Number
Referrers Email*
Service User Referred By
Service User Referred By (other)
Person being referred
First Name*
Last Name
Address line 1
Address line 2
Town/City*
Postal Code
Mobile
Phone
Email
Preferred Method of Communication
Contact by Email?
Contact by SMS?
Contact by Letter?
Service area*
What Support is needed? (You can select more than one) *
What Support is needed? (You can select more than one)
If referring to a dietitian please answer the next 3 questions
Height
Weight
Are they Diabetic?
Emergency Contact Name
Emergency Contact Number
Birth Date*
Gender*
Other Gender
Gender ID same as birth*
Ethnic Group*
Other Ethnic Group
Country of birth*
Sexual orientation*
Other Sexual Orientation
Do you have a disability*
Disability type*
Disability details
Faith*
Do you have dependants?
Dependant 1 Name
Dependant 1 DOB
Dependant 2 Name
Dependant 2 DOB
Dependant 3 Name
Dependant 3 DOB
Dependant 4 Name
Dependant 4 DOB
Are members of your household aware of your HIV status*
Which GUM Clinic do you attend?
GUM Clinic (other)
HIV status*
Do you smoke*
Do you drink alcohol*
To the best of your knowledge has the referred person done or displayed any of the following:
Violence towards others
Aggressive Behaviour
Theft
Sexual Offences
Self Harm
Arson
Racial/Homophobic Harassment/Abuse
Accessing Service Under the Influence
If any of the above were answered as 'Yes' please give details
What support is most needed?
Any other Comments
Does the young person consent to the referral? *
Are they OUT to their parents/carers/guardians?*
Referrers Name
Organisation*
Referrers Organisation (other)
Phone Number*
Email*
Are the parents and guardians aware of referral?*
Are there other agencies involved? If so, who?*
Who is being referred
Preferred communication methods
Emergency Contact Name*
Emergency Contact Number*
What support is needed? You can select more than one.
Please give brief details of the issues they are experiencing
Name of school or college they attend.
Gender ID same as at birth?*