Referral Form - Proud North London
Personal information disclosed in this form is essential to allow staff at Proud North London (and parent organisation Kiki Youth Education CIC) to contact you and identify the support that you may required and need.

The information that you disclose to us is collected only with your explicit consent,  is used to contact you for the referral process and is held in accordance with all applicable data protection legislation, including the General DataProtection Regulations.

The information that you provide will only be discussed with yourself, the professional making the referral (if available) and Youth Group Staff

As an organisation we create reports to demonstrate impact of our services with external partners and
funders, your personal information is not shared and will information about you will be anonymised .

At all times when we share information of young people accessing our services, it will only occur with your explicit consent. We will only share your personal information with law enforcement or other authorities if required by applicable law (in line with our Safeguarding/Child Protection policies, where there are concerns about the safety of yourself and others).
Email *
Which Service are you interested in
 *
Who is making the referral? *
Contact details of professional making referral
Full Name of Young person
 *
Full Address
Date Of Birth *
MM
/
DD
/
YYYY
Mobile Number *
Email Address *
Sex (Recorded at Birth) *
Gender Identity (Current) *
Sexual Orientation *
Are you sexually active? *
Out Status *
Are you 'OUT' about your Gender Identity? If so, to whom?
Required
PERSONAL ISSUES
Any information you disclose in the following sections will help us better to support your needs when accessing Proud North London’s services. Please try to explain your circumstances to the best of your ability.
Home Life
Please indicate whether you have or you feel you have experienced any of the following at home dueto your sexual orientation or gender identity?
Are you at risk of being homesless due to your sexual orientation or gender identity?
Clear selection
Confirm that you (or young person being referred) are aged between 11-25 and are requiring LGBT+ Youth Support and agree to your information being used to contact you.
 *
Submit
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