becoming-a-member-self-referral

Personal Details

First Name: (required) Surname: (required)

Date of Birth: Ethnicity: (required)

Gender: (required)
MaleFemaleTransgenderOther
First Language: (required)

Address inc. postcode:

London Borough/City: (required) Email address (required)

Telephone:
OK to leave Voicemail? YesNo

 

Mobile:
OK to leave Voicemail? YesNo

 

Preferred Method of contact:

GP Name & Contact Details:


Programmes

Which programme are you interested in? HIVAdoptionYou Are Not Alone (YANA)

If you are interested in the HIV Programme, are you: HIV positiveAffected by HIV (Family Member/Significant Other is HIV positive)n/a


Reason for referral

Please tick all that apply:
Emotional supportTo connect with peersAdvice/advocacyInformation/learningOther

If you chose 'Other' above, please comment here:


How did you hear about Body & Soul?

Medical professionalOther professionalInternet searchWord of mouthOther

 

If you chose 'Other Professional' or 'Other' above please comment here:


Additional comments

Please feel free to use this space to tell us a bit more about things like your current circumstances, any other professional support you may be receiving, etc - Optional.

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