Referrer Details

Name: (required) Organisation:

Relationship to person being referred: (required)

Telephone: Email address: (required)

Address: (required)

Does the person know that you are making this referral? yesno

Personal Details for the individual being referred

First Name: (required) Surname: (required)

Date of Birth: Ethnicity: (required)

Gender: (required)
MaleFemaleTransgenderOtherFirst Language: (required)

Can the person being referred speak English? yesno(Please note that in order to engage with the programmes we run, members are required to hold a conversational English).

Address inc. postcode:

London Borough/City: Email address: (required)

Telephone:
OK to leave Voicemail? YesNo

Mobile:
OK to leave Voicemail? YesNo

Preferred Method of contact:

Hospital: Consultant:
Social Worker: Other Professional(s):

GP Name & Contact Details:

Programmes

Please indicate which programme you are referring the person to: HIVAdoptionYou Are Not Alone (YANA)

If referring to the HIV Programme, is the person: HIV positiveAffected by HIV (Family Member/Significant Other is HIV positive)n/a

Reason for referral

Please tick all that apply:

Emotional supportTo connect with peersAdvice/advocacyInformation/learningOther

If you chose 'Other' above, please comment here:

Additional comments to support this referral

Please use this space to add any relevant information, e.g. circumstances leading to the referral, current diagnoses and treatment, etc.