Pathways to Hope
Referral Form
Name
*
First Name
Last Name
Preferred Name:
Gender
Male
Female
Non-binary
Which set of pronouns would you like to be addressed by?
She/her
He/him
They/them
Other
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Day
-
Month
Year
Date
How would you prefer us to contact you?
*
Phone
Email
Would you be happy for us to leave a voice message on your telephone?
*
Yes
No
Would you be happy to receive appointment reminders via text?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of trauma you have experienced/witnessed:
*
Domestic Abuse
Childhood Sexual Abuse
Childhood Physical Abuse
Military Service or War
Physical Illness
Accident or Disaster
Bereavement (whether through death or life)
Adoption
Medical Emergency
Bullying
Childhood emotional abuse
Assault
Rape
Other
On a scale of 1 to 10, how much does your trauma impact your life?
*
1
2
3
4
5
6
7
8
9
10
Not at all
Every day
1 is Not at all, 10 is Every day
What attracted you to this project?
For certain aspects of the group wellbeing sessions, we will bring in external tutors such as someone to teach photography skills etc. Do you feel comfortable with both male and female tutors?
Yes
No
Do you feel comfortable in a mixed-gender group?
Yes
No
Do you feel comfortable with a counsellor who is a different gender to you?
Yes
No
Have you had counselling before?
Yes
No
How did you hear about Trauma Healing Together?
Please Select
Internet Search
Support Worker
GP
Festival
Other service
Friend/family
Social media
Other
Is this referral being made for you or on behalf of someone else?
Referral is being made on behalf of the above named person
Referral is being made for myself
Has the person you are referring been made aware of this referral and understands what it involves?
Yes
No
Do you have any access requirements you would like us to be aware of?
Submit
Should be Empty: