External Referral Form
Young person's details
Forename(s)
Last Name
Date of Birth
Gender
Please select...
Female
Male
Intersex
Non Binary
Other
Prefer not to say
Questioning
Queer
Unsure
Unknown
If gender other, please specify
Trans?
Please select...
Transgender
Cisgender
Questioning
Non Binary
Other
Prefer not to say
Unknown
Pronoun mostly used
Please select...
He
She
They
Other
Other pronoun mostly used
Pronoun sometimes used
Please select...
He
She
They
Other
Other pronoun sometimes used
Sexuality
Please select...
Bisexual
Gay
Heterosexual
Lesbian
Asexual
Pansexual
Queer
Questioning
Other
Prefer not to say
Unsure
If sexuality other, please specify
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
Country of origin
Please select...
England
Scotland
Wales
Northern Ireland
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African republic
Chad
Chile
China
Columbia
Comoros
Congo
Congo (Republic of)
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holland
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland (Republic of)
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia (Republic of)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova (Republic of)
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Russian Federation
Rwanda
Saint Kitts and Nevis
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Lucia
St. Vincent and the Grenadines
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
USA
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Yugoslavia
Zambia
Zimbabwe
Not known
Not known - Outside UK
Other area/Not known - Africa
Other area/Not known - Asia
Other area/Not known - Australasia
Other area/Not known - Europe
Other area/Not known - North America
Other area/Not known - South America
Other area/Not known - South East Asia
Place of birth
Immigration status
Please select...
UK national
A10 national
Asylum appellant
Asylum seeker
Discretionary leave (DL)
Exceptional leave to remain (ELR)
Failed asylum seeker
Failed HRT
Illegal entrant
Indefinite leave to remain (ILR)
Overstayer
Refugee
Other
Did not ask
Client did not wish to disclose
Immigration status - other
Does the young person 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
Does the young person's 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
Does the young person consider themselves to have a disability?
Please select...
Yes
No
If the Young Person has had a condition for more than 12 months.
If yes, please provide relevant details:
Does the young person have any access requirements?
Young person's contact information
Main Telephone Number
Email Address
Address Line 1
Address Line 2
Address Line 3 (Town)
Postcode
The post code must be in a valid UK format to submit the form (or it can be left blank).
If the young person has nowhere to live, where is their nearest city?
How would they like us to contact them
Please select...
email
phone call
text
whatsapp
other
Specify if Other
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
Have you ever experienced rough sleeping
Please select...
Yes
No
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
Client did not wish to disclose
Details of referral
Reason for referral
Have you identified any risk AKT should be aware of?
Energency contact
Emergency contact name
Contact number
Relationship?
Please select...
Aunt
Brother
Carer
Cousin
Daughter
Father
Father-in-law
Foster father
Foster mother
Friend
Grandfather
Grandmother
Husband
Mother
Mother-in-law
Neighbour
Nephew
Niece
Partner
Sister
Son
Stepfather
Stepmother
Uncle
Wife
Other
Referrer Details
Referrer First Name(s)
Referrer Last Name
Organisation
Referrer main phone number
Referrer e-mail address
How did you hear about AKT?
Is the young person aware you are making this referral?
Please select...
Yes
No
Consent
Does the young person consent to hearing about events and activities?
Please select...
Yes
No
Contact Information