LGBTQI+ Health and Wellbeing Referral Form
Our LGBTQ+ Health and Wellbeing Service is here to support your whole self.
Referrer Details
Who is making this referral?
Please Select
Referral from a professional
Self-referral
Name
Job Title
Organisation
Mobile
Email
Reason For Referral
Client Details
Are you currently experiencing any of the following?
I am struggling with my alcohol use
I am struggling with my drug use
I am struggling with both alcohol and drug use
I am in recovery from alcohol use
I am in recovery from drug use
I am in recovery from both alcohol and drug use
I am impacted by someone else's alcohol use
I am impacted by someone else's drug use
Prefer not to say
Forename
Surname
Date of Birth
Day
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Month
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December
Year
2036
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1920
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1918
1917
1916
1915
1914
1913
1912
1911
1910
Gender
Please Select
Male
Female
Non-binary
Transgender
Agender
Intersex
Queer
Questioning
Genderfluid
Self-describe
Prefer not to say
Self-describe gender
Pronouns
Ethnicity
Please Select
White - Scottish
White - Other British
White - Irish
White - Gypsy/Traveller
White - Polish
White - Other White
African - African, African Scottish or African British
African - Any Other African Ethnic Group
Arab, Arab Scottish, Arab British
Asian/Asian British - Pakistani, Pakistani Scottish or Pakistani British
Asian/Asian British - Indian, Indian Scottish or Indian British
Asian/Asian British - Bangladeshi, Bangladeshi Scottish, Bangladeshi British
Asian/Asian British - Chinese, Chinese Scottish or Chinese British
Asian/Asian British - Any Other Asian
Caribbean or Black - Caribbean, Caribbean Scottish or Caribbean British
Caribbean or Black - Black Scottish African
Caribbean or Black - Black British African
Any Mixed or Multiple Ethnic Group
Any Other Ethnic Background
Not disclosed
British
Turkish
Scottish
Address 1
Address 2
Address 3
Town
County
Postcode
Mobile
Email
What would you like support with from the service?
Murray's Initiative
How did you hear about Murray's Initiative?
Please Select
Murray's Initiative website
RethinkYourDrink website
Alcohol Awareness Stall
Social Media
Online Search
By doctor or health professional
By another service or organisation
I give consent for Murray's Initiative programme to store my submitted information on this form so they can respond to my enquiry. I declare that I have the permission from the participant to share the information on this form with Murray's Initiative's. I give consent for Murray’s Initiative's to share information with partner(s) referring me onto this programme. I agree that Murray's Initiative and its partners may share information for funding purposes. This information will be minimised where possible. I declare that information that I have given on this form are correct as far as I know. *
Please Select
I agree
Submit
