Hello there! Welcome to Sahir’s Self-Referral Form – your first step towards support and empowerment. Take your time with this, and remember, you're not alone in this journey. If you need assistance or have questions while filling out the form, feel free to call our office at 0151 673 1972 or send us an email at info@sahir.uk.com.

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* 1. Name

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* 2. Date of Birth

Date

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* 3. First Language / Languages Spoken

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* 4. Nationality

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* 5. Ethnicity

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* 6. Gender Identity

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* 7. Is your gender identity the same as the gender you were given at birth?

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* 8. Sexual Orientation

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* 9. Pronouns

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* 10. Address

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* 11. Local Authority Area

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* 13. Mobile / WhatsApp Number

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* 14. OK to leave voicemail?

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* 15. Preferred Contact Method

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* 16. Services You Are Interested In (Select all that apply)

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* 17. Are you a person living with HIV?

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* 18. Who knows about your status?

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* 19. Would you like us to contact you about an HIV test?

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* 20. Are you affected by HIV?

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* 21. Do you identify as LGBTQ+?

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* 22. Are you currently seeking asylum?

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* 23. If Yes please provide your Home Office / NASS reference number

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* 24. What Support Do You Need? (Select all that apply)

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* 25. Please describe what practical support you require

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* 26. Do you have any disabilities, health conditions, allergies or access needs we should be aware of?

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* 27. Please describe your needs

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* 28. Emergency Contact Name

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* 29. Emergency Contact Pronouns

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* 30. Relationship to you

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* 31. Emergency Contact Number

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* 32. Do you use the same name and pronouns with your Emergency Contact?

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* 33. I use...

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* 34. Is your Emergency Contact aware of your HIV status?

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* 35. Is your Emergency Contact aware that you are accessing Sahir support services?

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* 36. How Did You Hear About Sahir?

Below, you’ll find a series of important questions designed to tailor our support for your needs while ensuring safety for both you and our community. Your responses are treated with the utmost confidentiality.

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* 37. Are you currently taking any prescribed medication?

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* 38. If ‘Yes’ please describe

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* 39. Are you concerned about drug / alcohol use?

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* 40. If ‘Yes’ please describe

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* 41. Do you have any worries about domestic abuse?

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* 42. If ‘Yes’ please describe

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* 43. Do you have a diagnosed mental health condition?

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* 44. If ‘Yes’ please describe

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* 45. More particularly in the last 6-12 months, have you self-harmed or thought about doing so?

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* 46. If ‘Yes’ please describe

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* 47. Do you have any criminal convictions?

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* 48. If ‘Yes’ please describe

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* 49. Before we wrap things up, is there anything else you’d like to share or make us aware of. We’re here for you, so feel free to share openly.

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