“
”

SERVICE USER PROFILE

Priority Level
–None–High
Medium
Low

Full Name

Age:
–None–<16
17
18
19
20
21
22
23
24
25

Telephone Number

Service User’s Email Address

Preferred Name:

Gender:
–None–Female
Intersex
Male
Trans F-M
Trans M-F
Other
Prefer Not to Say

Has Gender Changed From Birth?:
–None–Yes
No
Worker has not asked
Prefer Not to Say

Birth Name should be recorded here if different from preferred name and still legally relevant:

Ethnic Background:
–None–Asian – Bangladeshi
Asian – British
Asian – Indian
Asian – Pakistani
Asian – Other
Black – African
Black – British
Black – Caribbean
Black – Other
White – British
White – Irish
White – European
White – Other
Other – Chinese
Other – Latin America
Other – Middle Eastern
Other – Mixed Ethnicity
Other – Prefer Not to Say

Sexual Orientation:
–None–Bisexual
Gay
Heterosexual
Lesbian
Other
Questioning

Service User's Religion or Belief:
–None–Agnostic
Atheist
Bahai
Buddhist
Christian
Hindu
Humanist
Jain
Jewish
Muslim
Rastafarian
Sikh
Zoroastrian
Other
Not Religious – related to sexuality or identity
Not religious general
Prefer not to say

Family’s Religion or Belief:
–None–Atheist
Bahai
Buddhist
Christian
Hindu
Humanest
Jain
Jewish
Muslim
Rastafarian
Sikh
Zoroastrian
None
Other
Prefer Not to Say

Is the Service User a Gypsy, Traveller or Roma?:

Disability:
–None–Blind or Visual Impairment
Deaf or Hearing Impaired
Learning Difficulty
Mental Health
Mobility
Other disability
Prefer not to say
No Disability

Communication and/or Disability Support Required:

Access to Public Funds:
–None–Yes
No
Unknown

Borough:
–None–Barking and Dagenham
Barnet
Bexley
Brent
Bromley
Camden
City of London
Croydon
Ealing
Enfield
Greenwich
Hackney
Hammersmith and Fulham
Haringey
Harrow
Havering
Hillingdon
Home Counties
Hounslow
Islington
Kensington and Chelsea
Kingston upon Thames
Lambeth
Lewisham
Merton
Newham
None-transient
Redbridge
Rest of Britain
Rest of World
Richmond
Southwark
Sutton
Tower Hamlets
Unknown
Waltham Forest
Wandsworth
Westminster
Not asked

Childcare Responsibilities:
–None–No
Not Asked
Yes

Adult Carer Responsibilities:
–None–No
Not Asked
Yes

HOUSING

Current Housing:
–None–B&B
Care
Co-op (long-term)
Co-op (short-life)
Custody
Ex/partner
Family
Friend
Hospital
Hostel
Housing association
Local Authority
Nightshelter
Other
Owner
Part Buy/Part Rent
Private rented
Refuge
Sofa-surfing-NFA
Squat
Street homeless-NFA
Tied
Traveller's site
Unknown
Not asked

Currently Homeless?:
–None–Yes
No
Unsure
Not Applicable

At Risk of Becoming Homeless?:
–None–Yes
No
Unsure
Already Homeless

Is Current Housing or Homelessness linked to Gender or Sexuality:
–None–Yes
No
Unsure

EDUCATION, TRAINING AND EMPLOYMENT (EET)

Current EET Status:
–None–Employed FT
Employed PT
Unemployed
In FT Education
In PT Education
On Training Program
Unable due to Health

Out of EET for more than 6 months:
–None–Yes
No
Unsure

Would like Support around EET?:
–None–Yes
No
Unsure

PRESENTING ISSUES

16 or 17 years old:

Asylum Seeker or Unclear Immigration:

Bullying or Harrassment:

Care Leaver:

Coming Out or Sexual Identity:

Depression or Anxiety:

Diagnosed with Mental Health Issues:

Discrimination:

Domestic Abuse:

Eating Disorders:

Risk of Exploitation:

Family Conflict:

Financial Abuse:

Forced Marriage or Honour Violence:

Gender Identity:

History of Offending:

HIV or Hep:

Isolation or Loneliness:

Relationships:

Religious or Cultural Conflict:

Self Harm or Suicidal Thoughts:

Self destructive Behaviour:

Sex Work:

Abuse Sexual:

Sexual Health:

Substance and Alcohol Abuse:

CRIME AND SAFETY

Within the last year, has the service user been a victim of any of the following? (tick all that apply)

Written Abuse:

Robbery:

Blackmail:

Damage to Property or Vehicle:

Honor Based Violence:

Forced Marriage:

Homophobic or Transphobic Incident:

Verbal Abuse:

Verbal Threats:

Attempted Physical Assault:

Physical Assault:

Domestic Violence:

Sexual Abuse:

Rape:

Who was the Perpetrator of the Crime?:
–None–Partner
Family
Cultural/relgious community members
Local youths
Local community (general)
Other
Not applicable

Was the Crime Reported to Police?:
–None–Yes to All
One or More was Not Reported
Not Applicable

Was the Service User Happy with Outcome/Police Response?:
–None–Yes
No
Unsure
Not Applicable

Would the Service User Consider talking to Galop about this?:
–None–Yes
No
Not Applicable

BACKGROUND OF CASE

SERVICES REQUESTED (INCLUDE WHAT YOU WILL PROVIDE)

Hate Crime:

Abuse at Home:

Sexual Abuse and Violence:

Domestic Abuse Support Group:

Problems with the Police:

Questions about Criminal Justice System:

Safety Planning Domestic Abuse:

Safety Planning Neighbourhoods:

19s and under Queer Youth Group:

Counselling Under 18s at Risk:

Counselling Domestic Abuse:

Employment and Personal Development:

HIV Prevention Group Work:

Mental Health Advocacy:

Call Back from our Housing Advice Line:

Info about our Housing Advice Drop In:

Supported Accommodation:

Assessment Regarding Housing Options:

Housing Advice and Information:

Housing Advocacy:

Interested in Carer Placement:

Mentoring:

REFERRING WORKERS DETAILS

Referring Worker’s Name:

Referring Worker’s Organisation:
–None–Galop
Stonewall Housing
PACE
THT
Albert Kennedy Trust

Referring Worker’s Email:

INFORMATION SHARING

The service user agrees to information being shared regarding the service users situation between LGBT Jigsaw partners (Stonewall Housing, Pace, Galop and AKT):