Counselling Registration Form

Welcome to the SRASAC Counselling registration form.

Counselling can be a rewarding and life-changing process which can support healing from trauma, but it can also be demanding and de-stabilising at times. For this reason, the SRASAC counselling service is not suitable for everyone, as a stable foundation is needed for counselling to work safely.

We have published our criteria for the service, which you can view here:

https://www.srasac.org.uk/information-for-professionals

Please ensure you have read these before completing the form to check you are suitable for the service.

Some questions below ask for sensitive information. All information you provide is confidential; this means it is kept safe and secure within SRASAC and will not be passed on to any other organisation.

If you have any questions, or need help to complete this form, please contact us on our Information and Support Line on 07517 100 757. It will take approximately 10 - 15 minutes to complete this form.

Please note that current waiting time from your initial assessment to start of counselling is approximately 6-12 months depending on how you choose to access your counselling.
SRASAC Counselling Registration Form
Are you filling this registration form out for yourself, or another person?

For MyselfFor Another Person
Please note, SRASAC is self-referral only and does not accept third party referrals.

If you are wanting to refer a client into SRASAC, please send them the link to this registration form, where they can complete it themselves:

https://www.srasac.org.uk/counselling-registration-form

If a person is unable to complete the form independently, our information and support line can help walk them through it.
- The information and support line number is 07517 100 757.
- It's open Monday-Friday 9am-5pm
- Outside of these hours, clients can leave a voicemail and we'll get back to them.
Are you over the age of 18? (this registration form is for the adult counselling service)

YesNo
If you are under 18 (or supporting someone who is) please see our Children and Young People's service page for details of how to refer into our service.

https://www.srasac.org.uk/children-and-young-peoples-counselling
- Contact Information
- Legal Name*
  
  First NameLast Name
- Preferred Name for use by SRASAC Staff (optional)
- Date of Birth*
  
  DayMonthYear
  Date
- Gender*
  
  WomanManTrans WomanTrans ManNon binary/gender expansivePrefer not to sayOther
- Is your gender the same as was assigned at birth?*
- What are your preferred pronouns?
  
  She/herHe/HimThey/ThemOther
- Your home address - Please be aware that due to the limitations of our funding, we only accept referrals from people living permanently in the City of Sheffield, who pay council tax to Sheffield City Council, and we cannot accept referrals from people living in surrounding areas e.g. Dronfield, Rotherham, Worksop, Barnsley (etc).*
  
  Street Address
  
  Street Address Line 2
  
  City
  
  Postcode
- Email:*
  example@example.com
- Mobile Phone Number: *
- Landline Phone Number (optional):
- Please make it as easy as possible for us to support you by selecting the ways that are safe for us to use when contacting you:*
  
  Mobile PhoneEmailTextLeaving a voicemailPost
- Name of GP Surgery:*
- Telephone Number of GP Surgery *
- Preferred GP (if known):
- Your Situation :
  
  These question help us to understand more about you and your current situation.
- Marital Status*
  
  SinglePartnerMarriedCivil PartnershipSeparatedDivorcedPartner DeceasedOther
- Domestic/Family*
  
  Living in shared accommodationLiving aloneLiving with a partnerLiving with relatives/friendsLiving with parents/guardianLiving in temporary accommodationLiving in sheltered / supported accommodationLiving in a refuge/emergency housing (E.G. Sheffield Women's Aid or Young Women's Housing Project)Living in hospital or secure organisationLiving in longer term temporary/ dispersed accommodation whilst seeking asylumOther
- Caring Responsibilities / Pregnancy*
  
  No caring responsibilitiesPregnantCaring for 1 or more child under 6 monthsCaring for 1 or more child under 5 years oldCaring for 1 or more child over 5 years oldCaring for a child with a disabilityCaring for an adult with a disabilityCaring for an elderly personI am a young carer (I am under 16 years of age with caring responsibilities)
- Employment and Education*
  
  Employed - Full-timeEmployed - Part-timeEmployed on a temporary contractSelf-employedUnemployedIn education (in school/college)Attending Sheffield Hallam UniAttending Sheffield UniDisabled/SickCarer (including homemaker)VolunteerRetired
- Benefits (if receiving)
  
  Universal CreditPIP/DLAHousing BenefitIncome SupportESAWorking Tax CreditOther
- Where did you hear about SRASAC?*
  
  Internet search/SRASAC WebsiteSocial MediaFriend / Family memberGPIAPTSupport WorkerIDVAISVAPoliceSARC AdultSARC ChildrenTeacher/College/UniversityHospitalMASTCommunity Mental Health TeamCAMHSOther
- If we were recommended to you by a health or social care professional, please provide their name and organisation (if known):
- Have you used our Counselling Service before?*
- Do you need an Interpreter?*
- What is your first language?*
  
  AlbanianBosnianCantoneseCzechFarsi (Afghan)Farsi (Persian)FrenchGermanGujuratiHindiHindiItalianJapaneseKurdishMandarinNepaliPolishPunjabiRomanianRussianSlovakSomaliThaiTurkishUkranianUrduOther
- Do you have enough understanding of English for us to telephone you to arrange an initial assessment?*
- If the answer is no, please provide a named person we can contact on your behalf to arrange an appointment for you:
- Contact number of named person:
- Are you a refugee or asylum seeker? *
- Are there any immigration issues to be considered?*
- Ethnicity*
  
  White BritishWhite irishWhite EuropeanWhite - otherAsian / Asian British - IndianAsian / Asian British - PakistaniAsian / Asian British - BangladeshiAsian / Asian British - otherBlack/Black British - CaribbeanBlack/Black British - AfricanBlack/Black British - OtherAny Chinese BackgroundAny Traveller or Roma BackgroundYemeniWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther
- Sexual Orientation*
- Religion*
- Do you have a disability or long term illness (including Mental Health)?*
- Disabilities (please tick any which are relevant to you)*
  
  Mental HealthMobilityVisionHearingSpeechEpilepsyAutism/Autism SpectrumADHDDyslexia/DyspraxiaLearning DisabilityOther
- Do you require any special adjustments in order to access counselling because of your disability? If so, please give details below:
- Please indicate any mental health issues you are experiencing, or have experienced in the past.
- Depression*
  
  CurrentPreviousNever
- Anxiety*
  
  CurrentPreviousNever
- Post-Traumatic Stress Disorder (PTSD)*
  
  CurrentPreviousNever
- Eating Disorder*
  
  CurrentPreviousNever
- Psychosis*
  
  CurrentPreviousNever
- Thoughts of Self-harm*
  
  CurrentPreviousNever
- Self-harm*
  
  CurrentPreviousNever
- Do you have any thoughts of Suicide*
  
  CurrentPreviousNever
- Have you attempted Suicide?*
  
  Recently (within 6 months)Previous (anything over 6 months)Never
- Alcohol Misuse*
  
  CurrentPreviousNever
- Substance Misuse (Including all illegal drugs and misuse of prescription drugs)*
  
  CurrentPreviousNever
- Please give details about your current issues with alcohol or substance abuse.
- If you are receiving support for you alcohol and/or substance misuse, please provide details below:
- Is there any other mental health condition / symptom you have that is important for us to be aware of?
- Please select which mental health medications you are taking:*
  
  Anti-DepressantsAnti-PsychoticsAnti-Anxiety MedicationSleeping TabletsMood StabilisersI am not currently taking mental health medicationOther
- Which of these services have you used before for emotional or psychological support?*
  
  No previous psychological supportIAPT counsellor at a GP practiceWorkplace CounsellorCollege/University CounsellorCounsellor in a Voluntary OrganisaitonCommunity Mental Health TeamPsychiatric CarePsychotherapy/Psychological Treatment (specialist team)Hospital Day CareHospital AdmissionPrivate CounsellingCAMHS Counsellor/PsychologistSupport Group or Group TherapyOther
- Are there any mental health professionals involved with your care at the moment?*
- If you have answered YES to previous question, please provide details below
- Please select any traumatic incidents that you have experienced/are experiencing:
- Rape
  
  ChildhoodAdulthood (over 1 year ago)Within the last 1 year
- Sexual Assault
  
  ChildhoodAdulthood (over 1 year ago)Within the last 1 year
- Attempted Rape
  
  ChildhoodAdulthood (over 1 year ago)Within the last 1 year
- Sexual Exploitation (a person has taken sexual advantage of your vulnerable state)
  
  ChildhoodAdulthood (over 1 year ago)Within the last 1 year
- Grooming (when an adult builds a relationship, trust and emotional connection with a child or extremely vulnerable person in order to sexually exploit or harm them)
  
  ChildhoodAdulthood (over 1 year ago)Within the last 1 year
- Spiking
  
  ChildhoodAdulthood (over 1 year ago)Within the last 1 year
- Domestic Abuse
  
  ChildhoodAdulthood (over 1 year ago)Within the last 1 year
- Trafficking / Sexual Slavery
  
  ChildhoodAdulthood (over 1 year ago)Within the last 1 year
- Kidnap/Abduction
  
  ChildhoodAdulthood (over 1 year ago)Within the last 1 year
- Safeguarding and Risk
- Are you at risk of abuse/violence from another person/people at the moment?*
- If you answered YES to the previous question, please provide further information below. This information will not be shared outside of the organisation. If you are living in an unsafe environment or currently experiencing trauma or abuse, such as domestic and/or sexual abuse it is unlikely that you will be suitable for the service at this time.
- Are there any safeguarding/child protection issues that you might find helpful to discuss at your pre-counselling assessment?*
- If you answered YES to the previous question, please provide further information below*
- Do you have a history of violence or abusive behaviour towards another person or people, including sexual violence?*
- If you answered YES to the previous question, please give us more information below.*
- Have you ever been convicted of (or are currently being investigated for) any of the following criminal offences:*
  
  I have not been convicted of any offence connected to physical, emotional or sexual abuse.AssaultBatteryActual Bodily HarmGrievous Bodily HarmManslaughterMurderKidnapRape/Sexual AssaultGroomingHarassmentStalkingIllegal PornographyAny other offence related to physical, emotional or sexual abuse (please state)
- Please state any further information relating to the above offences which may be relevant, e.g. year of conviction, stage of investigation, etc. *
- We recognise that our clients have a right to express their feelings, but do not have a right to abuse, threaten, or attack (physically or verbally) any person whilst on SRASAC premises. This behaviour will not be tolerated and will result in withdrawal of our service.
- It is important before you begin your counselling that you understand what happens to the information you tell us.
  
  Please read the following and tick the box to let us know you understand how your personal information will be protected. Your privacy, confidentiality and safety are important to us. If we are concerned about your safety or the safety of someone else we may need to inform another agency, such as your GP or the Police, using the information you have given to us.
  
  Your contact details and counselling notes are stored on a secure electronic case management system and cannot be accessed by any other agency. Your assessment notes and counselling notes may be requested by other professionals, for example if you are going through the criminal justice system. We will contact you if any request is made for access to your counselling notes. You can also have access to your notes at any time. You can do this by putting your request in writing to us.
- Please check you have answered all the questions and read the statement above, then click on the SUBMIT button to submit your registration form. We aim to respond to your submission within 72 hours.
- Should be Empty:

SRASAC Counselling Registration Form

Contact Information

Your Situation :

Please indicate any mental health issues you are experiencing, or have experienced in the past.

Please select any traumatic incidents that you have experienced/are experiencing:

Safeguarding and Risk

Please check you have answered all the questions and read the statement above, then click on the SUBMIT button to submit your registration form. We aim to respond to your submission within 72 hours.