Your DetailsYour Name First Last Organisation Email Enter Email Confirm Email PhoneService User InformationName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY First Language Nationality Ethnicity Address(Required) Street Address Address Line 2 City Post code Email(Required) Enter Email Confirm Email PhoneOK to leave voicemail?(Required) YesNoPreferred Contact Method EmailPhoneSexuality & Gender IdentityGender Identity Man (Including Trans Man)Woman (Including Trans Women)Non-binaryAnother wayHow a person feels about and knows themselves to be. This might be as a woman, a man, as both, as neither, or in another way.If ‘another way’ please specify Is the person's gender identity the same as the gender they were given at birth? Yes No Pronouns She/HerHe/HimThey/ThemAnother wayA pronoun is a word that is used to refer to someone or something when you do not need to use a noun.If ‘another way’ please specify Sexual Orientation AsexualBisexualGayLesbianQueerHeterosexualAnother wayThe part of a person’s identity that describes who they experience attraction to, often but not always based on gender.If ‘another way’ please specify ServicesWhich Sahir services are you making the referral to?Please chooseHIV SupportLGBTQ+ SupportLGBTQ+ Refugee & Asylum SupportIf you are making a referral to our HIV Support Service, is the person: Living with HIVAffected by HIVOtherReason for ReferralWhat help and/or support do you think you need? Practical Support Advice & Information Counselling To connect with peers Other If ‘Other’ please specify Important InformationWould you consider the person to have ‘multiple barriers’? Yes No A person with ‘multiple barriers’ is someone with two or more needs affecting their physical, mental, social or financial wellbeing. Such needs typically interact with and exacerbate one another leading to individuals experiencing several problems simultaneously. Individuals with complex needs are often at, or vulnerable to reaching crisis point and experience barriers to accessing services; usually requiring support from two or more services/agenciesDoes this person have any history that would make you consider them to be at risk? Yes No An “Adult at Risk” is defined as any person aged 18 years and over who is or may need community care services by reason of mental health issues, learning or physical disability, sensory impairment, age or illness and who is or may be unable to take care of themselves or unable to protect themselves against significant harm or serious exploitation.If you have answered 'yes' to either question above, please provide further summary detail below. Do you have any other comments you wish to make?NameThis field is for validation purposes and should be left unchanged.
