Welcome to HSTAR Scotland SCIO Self-Referral Form
Our purpose is to support women in rebuilding their lives after experiencing trauma and abuse. HSTAR offers trauma-sensitive, person-centred support to women affected by past trauma, abuse, and mental health challenges. All information provided in this form will be kept confidential and will not be shared outside the charity without your explicit written consent. However, in rare cases where there is a credible risk of harm, we reserve the right to breach confidentiality.
Eligibility
We aim to provide free services to all eligible women in the Forth Valley. However, please be aware that fully funded services may not always be available due to changing funding situations and current projects. If there is no secured funding for your area, we will offer you the choice of either partially funded sessions or placement on a waiting list. If you live outside the Forth Valley area, we can only offer counselling services on a partially funded basis.
1.
We can accept referrals from women who are over 16 years old, reside in Scotland, and are in a safe personal space/environment. After receiving your referral, we will conduct your intake assessment telephone call within a maximum of 4 weeks. If eligible for our services, the average timeline to be matched with one of our therapists and begin trauma recovery therapy is 6 weeks, based on your needs and availability.
2.
You may be matched with therapists in training who are completing their placement with HSTAR Scotland. All student therapists are thoroughly screened, insured, registered members of COSCA/BACP, and receive full clinical supervision.
3.
We operate a minimum 24-hour cancellation policy. If you cancel your session with less than 24 hours’ notice or do not attend your appointment, HSTAR Scotland will issue you a late cancellation fee of £40, which must be paid before your next session can be booked. HSTAR Scotland provides short-term support (up to 18 therapy sessions; other services may vary). In line with our support model, only two cancellations are permitted within the allocated service block. As a small charity, our cancellation policy is essential because we rely on timely communication to effectively manage our limited resources and continue offering vital services to those in need. We appreciate your understanding and cooperation
4.
For therapy and mental health and wellbeing sessions you will be required weekly attendance; we do not offer flexible or biweekly scheduling options.
5.
Based on our terms and conditions and current funding availability, you may be required to pay a refundable deposit of £40. This deposit will be returned to your nominated bank account within 14 working days following your final session with our services. Please note, the refundable deposit scheme does not apply to partially funded therapy.
6.
We will offer you a therapy modality based on your individual healing needs and matched with the availability of a suitable therapist.
7.
We will be contacting you via email or telephone during your engagement with HSTAR. We ask for your active engagement and to reply to our emails or returning our calls within maximum 5 working days. We might close your file if you remain unresponsive.
Receiving Therapy Elsewhere
You must notify us about any ongoing medical treatment about your physical and mental health wellbeing. This is to assure that we fulfil our duty of care and that the support you receive is not inadequate or harmful.
In order to continue with this referral please tick to confirm that you are NOT currently receiving any counselling or therapy elsewhere. * I confirm
Yes
SELF HARM / SUICIDAL RISK
HSTAR is not an emergency service, and we may not be able to assist you with therapy services if you are actively experiencing suicidal ideations, engaging in significant self-harm, or unable to keep yourself safe. If your mood deteriorates and you need urgent help, please contact one of the following: GP ‘out of hours' service, 111 who can put you through to an out of hours doctor or help if necessary; Samaritans: Telephone support, Tel. 116 123 Hours: 24 hours, 7 days a week Samaritans website: www.samaritans.org; In an extreme emergency call 999 for an ambulance or go to the nearest Emergency Department; Your GP in surgery hours.
In order to continue with this referral please tick to confirm that you are NOT currently feeling suicidal or engage in significant self harm behaviours and can keep yourself safe * I confirm
*
Yes
Personal Information
Please tell us a little bit about yourself.
Full Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date Picker Icon
Gender
*
Country of birth/ethnicity?
*
Preferred language
*
Address
*
Street Address
Street Address Line 2
City/town
State
Postcode
Phone number
*
National Insurance Number
*
E-mail
*
example@example.com
How would you prefer us to contact you?
*
Phone Call
Text Message
Email
Other
Would you be happy for us to leave a voice message and text on your telephone?
*
Yes
No
Our therapists working hours are: Monday - Friday 9am - 4pm. However we may try to allocate a therapy online between 4pm - 7pm (very low availability, and waiting time can take longer). Please share your availability for therapy.
*
Monday 9am -12pm
Monday 12pm - 4pm
Tuesday 9am -12pm
Tuesday 12pm - 4pm
Wednesday 9am -12pm
Wednesday 12pm - 4pm
Thursday 9am -12pm
Thursday 12pm - 4pm
Friday 9am - 12pm
Friday 12pm - 4pm
Monday - Friday 4pm - 7pm ONLINE THERAPY ONLY
Other
Would you consider a male therapist?
*
Yes
No
Would you consider a male therapist?
*
Yes
No
Emergency contact
Full Name
*
First Name
Last Name
Their phone number
*
Relation to you
*
Which GP practice are you registered with?
Name of GP Practice
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Reason for contacting HSTAR Scotland
Please select the options below that match your situation.
Type of trauma you have experienced/witnessed:
*
Domestic Abuse
Sexual Abuse
Childhood Emotional Abuse
Childhood Physical Abuse
Childhood Sexual Abuse
Terrorist Attack / War
Ethnicity
Religion / Faith
Gender/ Sexuality
Bereavement
Adoption / Social Care
Bullying
Health/ Medical Condition
Assault
Other
What services are you interested in?
*
Safety Planning
Mental Health Wellbeing 1-2-1
1-2-1 therapy
CICA and Advocacy support
Group sessions
Coffee and chat
Walking therapy
Workshops
On a scale of 1 to 10, how much has trauma impacted 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
In your words could you describe why are you seeking support from HSTAR Scotland?
*
If you feel comfortable, please share any information about any current or past experiences with self-harm or thoughts of suicide. This includes whether you are currently having any such thoughts, if you have attempted suicide in the past 12 weeks, or any other relevant history related to these risks. Providing this information helps us support you safely and effectively.
*
Please disclose if you experienced any self-harm or suicidal thoughts/attempts within the last 12 weeks, or/and if you made plans to end your life?
*
Are you currently taking any prescribed medication or self-medicating? If yes, please specify the medication name and dosage.
*
Do you have a history of any physical or mental health difficulties or diagnoses? If yes, please share any support you have received or contact you have had with health or support services in the past.
*
In the last 6 months have you received any form of therapy, care or treatment from services for your physical and/or mental health difficulties?
*
Do you currently use drugs or alcohol?* If Yes, please give details and amount
*
How did you hear about the service?
*
Our Other Supportive Services
Our objective is to advance emotional and mental health well-being through the provision of responsive multicultural and multilingual counselling support for women who have been affected by trauma. We are promoting mental health care awareness, hosting multicultural events, delivering focused training, offering befriending activities, and other mental health wellbeing support programmes. It is the main goal of our service to assist you as a woman in exploring and understanding your recovery. You can reclaim your life reactions, and responses in this period of emotional upheaval, anxiety, and despair. All so that you can re-establish your sense of inner balance, perspective, and purpose. We can provide a confidential and supportive space in which calm reflection will enable you to take stock of your experiences, feelings, thoughts, and sensations.Our emotional support practitioners can offer a safe and empathetic space to express - usually online or by telephone - their thoughts and feelings about issues that confront them. It is not about giving our ladies advice or telling them how to be. Rather, the service is designed to help them explore what has happened, what they are experiencing and how they can rebuild their inner strength and self-confidence.
Confidentiality and Privacy
Respecting your confidentiality and privacy is fundamental to our practice. Your form will be stored securely and governed in line with our GDPR. We will not share your information with anyone outside our practice, unless we believe you are at imminent risk of harm (or a child or vulnerable adult is at a serious risk). In this instance we are legally bound to share basic information in order to keep you (or a vulnerable other) safe. *
I have read and I understand this privacy information
*
Yes
Do you have a question you would like us to answer?
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