Sex Workers' Outreach Project Referral Form
Page 1
Are you referring yourself?
Please select...
Yes
No
Page 2
Referring service details
Name of service
Service type
Please select...
Advice agency
Community mental health services
Community substance misuse services
Day centre
Domestic violence service
Drug / alcohol service
Faith organisation
Floating support
GP / Hospital / Health authority
Hostel
Job Centre Plus
Local authority - adult social services
Local authority - children's service
Local authority - housing / homelessness department
Local authority - other
Local authority - probation services
Night shelter
Outreach / No Second Night Out (NSNO) team
Police / safer streets team
Prison
Rolling shelter
Sexual health service
Sexual violence services
Social services
Other
Your full name
Phone
Email
Client contact details
First name
Last name
Date of birth
(DD/MM/YYYY)
Phone
Email
Address 1
Address 2
Town / City
County
Country
Please select...
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Postcode
Date moved in at this address
(DD/MM/YYYY)
If the exact date is unknown, please give your best estimate.
Equality and diversity
Gender
Please select...
Male
Female
Non-binary
Other (please specify)
Prefer not to say
Other gender:
Does the client have a disability or health condition?
Please select...
Yes
No
Prefer not to say
What is the impact of the disability or health condition on their life?
Sexual orientation
Please select...
Bisexual
Gay
Heterosexual
Lesbian
Other (please specify)
Prefer not to say
Other sexual orientation:
Ethnic origin
Please select...
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Indian
Asian/Asian British: Other (please specify)
Asian/Asian British: Pakistani
Asian/Asian British: Prefer not to say
Black/Black British: African
Black/Black British: Caribbean
Black/Black British: Other (please specify)
Black/Black British: Prefer not to say
Mixed: Other (please specify)
Mixed: Prefer not to say
Mixed: White & Asian
Mixed: White & Black African
Mixed: White & Black Caribbean
White: British
White: English
White: Gypsy or Irish Traveller
White: Irish
White: Northern Irish
White: Other (please specify)
White: Prefer not to say
White: Scottish
White: Welsh
Other ethnic group: Arab
Other ethnic group: Prefer not to say
Other (please specify)
Prefer not to say
Did not ask
Other ethnic origin:
Your contact details
Name or Working name
Phone
Email
Page 3
Reasons for referral - please tick all that apply.
Referral reasons
Sex work (current)
Yes
No
Previous sex work
Yes
No
Possibly involved in sex work
Yes
No
Sexual health concerns
Yes
No
Support with leaving/reducing sex work
Yes
No
Support with accessing health support services
Yes
No
Client requires additional (outreach) support in order to access or reengage with:
Substance misuse support and services
Yes
No
Sexual health services
Yes
No
Employment / Career services
Yes
No
Money or benefit advice
Yes
No
Other services:
Any known risk factors:
Risk factors
Overdose history
Yes
No
Overdose history - relevant details
Mental health
Yes
No
Mental health - relevant details
Domestic violence
Yes
No
Domestic violence - relevant details
Street homeless
Yes
No
Street homeless - relevant details
Sexual / financial exploitation by others
Yes
No
Exploitation - relevant details
Other:
Any history of violence or aggression?
Yes
No
Violence/aggression - relevant details:
Consent to be contacted
Can we contact you?
Yes
No
Is it OK to leave you a voicemail message?
Yes
No
Is it OK to send you a text message?
Yes
No
Preferred contact times:
Please tell us how we can help:
Page 4
Client's family
Does the client have children under 18?
Please select...
Yes
No
Did not ask
Client did not wish to disclose
Are the children residing with the client?
Please select...
Yes
No
Did not ask
Client did not wish to disclose
Please provide details of who/ages:
Please let us know how we can help
Consent to contact
Has the client given permission for us to contact them?
Yes
No
Is it OK to leave a voicemail message?
Yes
No
Is it OK to send a text message?
Yes
No
Contact Information