Stepping Stones Referral Form

Our next cohort of Stepping Stones will be running in August 2026.

Name

First NameLast Name

Preferred Name:

Gender

Which set of pronouns would you like to be addressed by?

Other

Do you have access to a device which gives you access the internet

Unfortunately, these sessions are held online so will require you to be able to access the internet.

The sessions will be held via zoom which can be downloaded to most phones, tablets or computers.

We will send out information about how to access zoom before the sessions are due to start.

Email

example@example.com

Phone Number

Area CodePhone Number

Date of Birth

Date

Age Bracket

Address

Street Address

Street Address Line 2

Town

County

Postcode

Type of trauma you have experienced/witnessed:

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

1 is Not at all, 10 is Every day

What attracted you to this project?

How did you hear about Trauma Healing Together?

Only if you feel comfortable answering, please select any of the following you have experienced. This information will be used for research purposes only and will help us better understand how trauma impacts people. Any answer you provide will not impact your ability to access our service.

We strive to create a welcoming space which is Neurodiverse friendly. As such, it can be useful to know how many Neurodiverse individuals we support through our service. Please tick the box if you have been diagnosed or self-identify as Neurodivergent.

Should you wish to, please use this space to provide more information about the type of neurodiversity you experience.