URLThis field is for validation purposes and should be left unchanged.Hello there! Welcome to Sahir’s Self-Referral Form – your first step towards support and empowerment. Take your time with this, and remember, you're not alone in this journey. If you need assistance or have questions while filling out the form, feel free to call our office at 0151 673 1972 or send us an email at info@sahir.org.uk. Your Personal DetailsName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY First Language(Required)Nationality(Required)Ethnicity(Required)Do you require a Translator?(Required)YesNoIf yes, please specify which languageLet’s celebrate your uniqueness! How you define yourself is important to us. Please share which of the following best describes your gender identity, sexual orientation and preferred pronouns.Your Gender Identity(Required) 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 specifyIs your gender identity the same as the gender you were given at birth?(Required) Yes No Your Pronouns(Required) 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 specifyYour Sexual Orientation(Required) 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 specifyLet’s stay connected. Please share your current contact information, and if you can, two ways for us to reach you. Just a heads up, we will try to contact you at least 3 times on receipt of this form. If any of your details change, please give us a shout and let us know. Your Contact InformationAddress(Required) Street Address Address Line 2 City Post code Email(Required) Enter Email Confirm Email PhoneOK to leave voicemail?(Required) YesNoPreferred Contact Method(Required) EmailPhoneNow let’s dive into some questions to understand the kind of services and support you’re looking for.Which services are you interested in?(Required)Please chooseHIV SupportLGBTQ+ SupportLGBTQ+ Refugee & Asylum SupportAre you(Required) Living with HIVAffected by HIVOtherDo you identify as LGBTQ+?(Required) YesNoUnsure/QuestioningWhat help and/or support do you think you need?(Required) Practical Support Advice & Information Counselling To connect with peers Other If ‘Other’ please specifyHow did you hear about Sahir?(Required) Word of Mouth GP / Hospital Consultant Social Media Another Service Newspaper/Magazine Website Accessed Sahir Before Other If ‘Another Service’ or ‘Other’ please specifyTell us a little more about why you would like to access our services:(Required)
