Self-Referral Form
Contact Details
Forename(s)
Last Name
Email address
Main telephone number
Address Line 1
Address Line 2
Address Line 3 (Town)
Postcode
If you have nowhere to live, where is your nearest city?
How would you like us to contact you?
Please select...
email
phone call
text
whatsapp
other
Specify if other
Our opening times are 9am – 5pm, Monday to Friday. When is it best to contact you?
Type of housing
Please select...
Foster care
Hotel
LA Temp accommodation
Living independently
Living with family
Living with partner
Lodging
Refuge
Rough sleeping
Sharing with friends
Shorthold tenancy
Social housing
Sofa surfing
Squatting
Student accommodation
Supported accommodation
Social Care funded accommodation
Have you ever experienced rough sleeping?
Please select...
Yes
No
About You
Date of birth
dd/mm/yyyy
Age
Gender
Please select...
Male
Female
Intersex
Non Binary
Other
Prefer not to say
Questioning
Queer
Unknown
Unsure
Sexuality
Please select...
Bisexual
Gay
Heterosexual
Lesbian
Pansexual
Asexual
Queer
Intersex
Questioning
Other
Prefer not to say
Unsure
If gender other, please specify
If sexuality other, please specify
Pronoun mostly used
Please select...
He
She
They
Other
Pronoun sometimes used
Please select...
He
She
They
Other
Other pronoun mostly used
Other pronoun sometimes used
Ethnicity
Please select...
Arab
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: Other
Black/Black British: Caribbean
Black/Black British: African
Black/Black British: Other
Chinese/Other ethnic group:Chinese
Chinese/Other ethnic group: Other
Gypsy/Irish Traveller
Mixed: White & Black Caribbean
Mixed: White & Black African
Mixed: White & Asian
Mixed: Other
White: British
White: Irish
White: Other
Client did not wish to disclose
Did not ask
Do you have a Faith or Religion?
Please select...
Agnostic
Any other religion
Atheist
Baha'i
Buddhist
Christian (all denominations)
Hindu
Jewish
Muslim
Rastafarian
Sikh
Client did not wish to disclose
Did not ask
Other
None
Do your family have a faith/religion?
Please select...
Agnostic
Any other religion
Atheist
Baha'i
Buddhist
Christian (all denominations)
Hindu
Jewish
Muslim
Rastafarian
Sikh
Client did not wish to disclose
Did not ask
Other
None
Religion - other
Family religion - other
Do you consider yourself to have a disability?
Please select...
Yes
No
If you have had a condition for more than 12 months.
If yes, please provide relevant details:
Do you have any access requirements?
Preferred language
Please select...
English
Acholi
Albanian
Amharic
Angolan
Arabic
Bengali
British Sign Language (BSL)
Czech
Eritrean
Estonia
Ethiopian
Farsi
French
German
Greek
Hungarian
Italian
Krio
Kurdish
Latvian
Lingala
Lithuanian
Ndebele
Polish
Portuguese
Punjabi
Romanian
Russian
Serbo-Croat
Slovakian
Slovenian
Somali
Spanish
Sudanese
Swahili
Swedish
Tigrinya
Turkish
Urdu
Yoruba
Did not ask
Client did not wish to disclose
Interpreter required?
Please select...
Yes
No
Did not ask
Did not wish to disclose
Is your gender different or have more components to the one assumed at birth?
Please select...
Yes
No
Not sure/questioning
Prefer not to say
Other
What is your gender identity?
Please select...
Agender
Demigirl
Demiboy
Female
Gender-Expansive
Gender fluid
Genderqueer
Intersex
Male
Nonbinary
Polygender
Trans man
Trans woman
Additional gender identity (if applicable)
Please select...
Agender
Demigirl
Demiboy
Female
Gender-Expansive
Gender fluid
Genderqueer
Intersex
Male
Nonbinary
Polygender
Trans man
Trans woman
Let us know if you have other identities we should be aware of.
Further Information
Reason for contact
How did you hear about us?
Please select...
Internet search
Media (TV, radio, article)
Instagram
Twitter
Facebook
Poster or flier (please state where this was below)
A friend
A family member
Another organisation (please state who below)
Somewhere (please state where below)
Where did they hear about us?
Please select...
Internet search
Media (TV, radio, article)
Instagram
Twitter
Facebook
Poster or flier (please state where this was below)
Don’t know
Other (please provide details below)
Details - how you heard about us
Contact Information