Self-Referral Form

PLEASE NOTE if you are a professional or an ally who is referring a young person, you will need to complete our External Referral form.

Our Digital (South West, Wales, Midlands, North West, East Anglia and South East) and Manchester teams are currently closed for referrals.

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 prefer us to contact you?

Specify if other

Our opening times are 9am – 5pm, Monday to Friday. When is it best to contact you?

Please tell us about any safety concerns you have about how and when we contact you?

Safe to call?

Safe to Whatsapp?

Safe to text?

Safe to email?

Type of housing

Have you ever experienced rough sleeping?

About You

Date of birth

Please write as dd/mm/yyyy

Age

Sexuality

If sexuality other, please specify

Pronoun mostly used

Pronoun sometimes used

Other pronoun mostly used

Other pronoun sometimes used

Ethnicity

Do you have a Faith or Religion?

Do your family have a faith/religion?

Religion - other

Family religion - other

Do you consider yourself to have a disability?

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

Interpreter required?

Is your gender different or have more components to the one assumed at birth?

What is your gender identity?

Additional gender identity (if applicable)

Let us know if you have other identities we should be aware of.

Further Information

Reason for contact

Have you had a caseworker at akt before?

How did you hear about us?

Details - how you heard about us

Contact Information