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 (Required.)

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2. Date of Birth (Required.)

Date

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3. First Language / Languages Spoken (Required.)

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4. Nationality (Required.)

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5. Ethnicity (Required.)

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6. Gender Identity (Required.)

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7. Is your gender identity the same as the gender you were given at birth? (Required.)

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8. Sexual Orientation (Required.)

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9. Pronouns (Required.)

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10. Address (Required.)

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11. Local Authority Area (Required.)

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13. Mobile / WhatsApp Number (Required.)

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14. OK to leave voicemail? (Required.)

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15. Preferred Contact Method (Required.)

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

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17. Are you a person living with HIV? (Required.)

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18. If yes, who knows about your status? (Required.)

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19. Would you like us to contact you about an HIV test? (Required.)

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20. Are you affected by HIV? (Required.)

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21. Do you identify as LGBTQ+? (Required.)

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22. What Support Do You Need? (Select all that apply) (Required.)

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23. Please describe what practical support you require (Required.)

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

This helps us understand if you need any extra support or adjustments to fully access our services. (Required.)

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25. If yes, please describe your needs (Required.)

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26. Emergency Contact Name (Required.)

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27. Emergency Contact Pronouns (Required.)

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28. Relationship to you (Required.)

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29. Emergency Contact Number (Required.)

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30. Do you use the same name and pronouns with your Emergency Contact? (Required.)

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31. I use... (Required.)

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32. Is your Emergency Contact aware of your HIV status? (Required.)

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33. Is your Emergency Contact aware that you are accessing Sahir support services? (Required.)

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34. How Did You Hear About Sahir? (Required.)

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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35. Are you currently taking any prescribed medication?

Knowing this helps our team understand your wellbeing and make sure any support we offer fits safely around your needs. (Required.)

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36. If ‘Yes’ please describe

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37. Are you concerned about drug / alcohol use?

We ask this so we can offer the right kind of support or signpost you to specialist services if needed – never to judge. (Required.)

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38. If ‘Yes’ please describe

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39. Do you have any worries about domestic abuse?

This can mean emotional, physical, financial or sexual abuse from a partner, family member or anyone close to you. We ask this so we can make sure you feel safe and supported, and can signpost you to specialist services if needed. (Required.)

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40. If ‘Yes’ please describe

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41. Do you have a diagnosed mental health condition?

We ask this to make sure we can offer you the right emotional or wellbeing support. (Required.)

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42. If ‘Yes’ please describe

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

This question helps us understand how best to support your mental and emotional safety. You won’t be judged for your response. (Required.)

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44. If ‘Yes’ please describe

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45. Do you have any criminal convictions?

We ask this to ensure that everyone accessing our services can do so safely. This information is kept strictly confidential. (Required.)

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46. If ‘Yes’ please describe

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47. 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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