Referral form

Referral form

Please complete the form below. If you want us to respond, you must provide a safe telephone number or email address.

Please note: you must complete all the fields (apart from last name, finance and benefits and specific access needs, which are optional). 





Preferred Pronoun:
Date of Birth:
Gender Identity:
Trans or Trans History?:
Sexuality:
Ethnicity:
Disability:
Religion:
Pregnancy / Childcare:
Relationship Status:
Borough:
Economic Status:
Weekly Income (-Housing Benefit):
Are you in fear of a partner, ex-partner or family member?:
Housing Situation:
Support Required or Requested:
Specific Access Needs?:
Professional Filling in Form for Someone:

Please note:

Once you have submitted the form, you will return to our homepage.  An email confirmation will be sent to the email address you have provided.

We review our drop-in sessions regularly to make sure we reach LGBT+ people across all London boroughs.

Monthly drop-in sessions

First Wednesday of every month: 5.30-7.00 pm
CliniQ
56 Dean Street
London W1D 6AQ

(for trans people)

All services are free and confidential.

All venues are accessible for people with disabilities.

No appointments necessary.

Pre-arranged appointments can be made for between 3.30 and 5.00 pm.