What is your name?

What are your contact details? Mob:Email: Other:

What is the safest way to contact you and when?

Would you like us to text you first to arrange a time to talk?

Please give us a brief description of any issues you may need support

with.

Do you need our support?We can offer you free 1-2-1 support if you are struggling

with your mental health and emotional well-being in relation to your sexuality and/or gender identity.

Please complete the information below and we will be in touch.

Are you questioning your gender/sexuality?

Are you aged between 12-25?

Are you LGBTQ+?

Are you struggling?

Please return referral forms via post or email:

Positive Identities Service, Trinity House, Blackwall, Halifax, HX12QR

Email:  kirsty.taylor@barnardos.org.uk/ jeanette.smith@barnardos.org.uk