Refer Someone to HIV Support Services

Your name * Name of your organisation * Your contact number * Your email address * What is the name of the person being referred? * Contact number of person being referred * In case we are unable to contact the person being referred by telephone, does the person referred give consent to being contacted via email? * If yes, what is their email address? Can MESMAC staff leave a message if they don't get hold of the person being referred? * Are there any times that they would prefer not to be contacted? * Is the person referred living with HIV? * What is their postcode? *

Please be aware that we only cover Bradford Metropolitan District postcode areas.

How old are they? * How do they describe their gender? * If you selected other, please specify Is this the gender they were assigned at birth? * Do they have a disability? * If yes, what disability or disabilities do they have?

We will contact you for more information and if we need to make any adjustments Please be aware that we only cover Bradford Metropolitan District postcode areas.

Do they have any mental health or neurodivergent conditions (anxiety, dyslexia, autism etc.) * What is their living circumstance? How will they get to our office? * Are they registered with an HIV clinic in the UK? Do they have enough medication? What are the main issue/s they would like to resolved with our support? * What days and times are most convenient for them? * Are they able to communicate easily in English? * If No, what language do they speak? Do they have mobility issues? * I have read and understood the Yorkshire MESMAC privacy statement and agree to the use of my data in line with this policy *

Find link to privacy policy at the bottom of the page