The Resilience Project
Referral Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred method of contact
Whatsapp
Phone
Email
Would you be happy for us to leave a voice message on your telephone?
Yes
No
Gender
Male
Female
Non-binary
What attracted you to this project?
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
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
If you were to take part in the course, which subjects would you most like to participate in:
Arts and Crafts
Photography
Yoga and Mindfulness
Nutrition
Horticulture/Gardening
Creative Writing
Cooking/Baking
Improving sleep
Fencing
Building Confidence
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
Have you had counselling before?
Yes
No
Submit
Should be Empty: