Please read before referring your client to us.
Our free of charge trauma recovery counselling is currently available to Forth Valley residents only. If your client is residing outside the Forth Valley area that we cannot cover the full costs of therapy. Our therapy will be offered at reduced charity rate of £30 per hour, and HSTAR will take responsibility of remaining costs of services. We understand that this may still be a significant expense for some individuals. However, until we secure additional funding, we regretfully cannot extend our free therapy support to beneficiaries residing outside the Forth Valley.
External Therapy Referral Form
A woman referred by your organisation must be over 16, must be a resident of Scotland and be in a safe place (we support survivors of trauma or abuse). The average waiting time from receiving referral to the first therapy session may take up to 6 weeks, the Intake Assessment call will be made within 4 weeks from the referral date. We prioritise inclusion and diversity across all our services and we welcome women: survivors with historical experience of domestic or sexual abuse, childhood sexual abuse or harmful practices from minoritised communities who have experiences of racism, discrimination, or social exclusion from refugee backgrounds with experience of trafficking or other human rights abuses from migrant backgrounds where English is not your first language (we offer therapy in 20 languages), currently coping with bereavement.
Referral Criteria:
Whilst we assess on a case-by-case basis, it may be that HSTAR Scotland is not the right place for you at this time. In order to avoid long waiting times and disappointment, please consider the following when making a referral. We may decide to turn down or postpone a referral where a woman: has a current complex mental health diagnosis, severe substance abuse issue or severe eating disorder is seeking counselling in order to support a court case or is court-mandated for therapy is currently living with a perpetrator of domestic or sexual abuse. Also you need to be sure that client is in a safe place, and there is no risk of self-harm or/and suicidal thoughts/ behaviour. Our intake assessment is not a guarantee of counselling, but we will always work with you to find the right service, whether at the HSTAR Scotland or another organisation. We recommend you and your organisation to assess each referred woman carefully for our therapy, so we can avoid her distress and disappointment. At the HSTAR Scotland we regard inquiries and counselling discussions as private and confidential. Any information provided will be treated in confidence. No information of any kind is given to anyone outside of the charity unless specifically requested in writing, although in rare circumstances we reserve the right to widen confidentiality if there appears to be a serious risk of harm.
Refundable Deposit
For free therapy we take a fully refundable deposit of £30 which is refunded to the client after therapy completion. Once you attended your 8-free sessions HSTAR will send them the deposit request form. Their deposit will be refunded directly to nominated bank account within 7 working days from the last session of our services. For paid therapy refundable deposit scheme does not apply.
Client Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Mobile Phone Number
*
National Insurance Number
*
Email
*
example@example.com
Birth Date
*
-
Day
-
Month
Year
Date
What is their employment status?
Employed
Unemployed
Retired
Self-employed
Disabled
Student
Homemaker
Other
Reason for Referral
Please explain briefly how HSTAR could support your client/patient
*
History
GP Practice Contact Details
*
Has your client/patient previously received any type of counselling or mental health services?
*
Yes
No
Unable to Answer
Please provide details
Is your client/patient currently receiving any type of counselling or mental health services?
*
Yes
No
Unable to Answer
Please provide details
Is your client/patient currently on prescribed drugs/medication?
*
Yes
No
Unable to Answer
Please provide details
Symptoms
Please answer all of the statements below that describe your client/patient concerns
Do they have
*
suicidal thoughts ****** please explain further
memory problems
sleeping disorder
struggled to explain myself to others
obsessive thoughts ****** please explain further
violent thoughts ****** please explain further
stress and tension
medical concerns
fatigue
work problems
None of above
Other
Type of trauma the referred person have experienced/witnessed:
*
Domestic Abuse
Sexual Abuse/ Rape
Childhood Emotional Abuse
Childhood Sexual Abuse
Childhood Physical Abuse
Ethnicity/ Faith/ Religion based
Terrorist Attack / War
Gender/ Sexuality
Bereavement
Adoption / Social Care
Health/ Medical Condition
Assault
Other
In order to continue with this referral please tick to confirm that your referee is NOT currently receiving any other counselling therapy, mental health treatment * I confirm
*
Yes, I confirm
In order to continue with this referral please tick to confirm that your referee is NOT currently feeling suicidal or engage in significant self harm behaviours and can keep yourself safe *I confirm
*
Yes, I confirm
In order to continue with this referral please tick to confirm that your referee will accept to be receiving therapy from fully supervised Therapist in Training * I confirm
*
Yes, I confirm
Referring Organisation/ Person Details
Your Name
*
First Name
Last Name
Organisation/Company
*
Mobile Phone Number
*
Your Email
*
example@example.com
Date
*
/
Month
/
Day
Year
Date
Submit
Should be Empty: