Waythrough Self-Referral Preferred Name Optional Legal Name Date of Birth Gender Identity (how the individual currently identifies) Does your gender identity match sex at birth? Yes No Unsure Contact details: Phone number and/or email address How would you like to be contacted? Telephone Optional Text Message Optional Email Optional Other Optional Sexuality Gay Lesbian Bisexual Heterosexual Questioning Other What do you need help with? Choose all that apply: Access to peer support (join our social group) Discrimination and bullying Emotional wellbeing Family/carer support Information and resources Help with coming out – gender Help with coming out – sexual orientation Healthy relationships Practical support Other (please state below) Please provide a brief overview of your current situation and needs: Optional
