Stepping Stones Referral Form

Stepping Stones

Referral Form
Our next cohort of Stepping Stones will be running in January 2026.
Name*

First NameLast Name
Preferred Name:
Gender
Which set of pronouns would you like to be addressed by?

She/herHe/himThey/themOther
Do you have access to a device which gives you access the internet*

YesNo
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*

DayMonthYear
Date
Age Bracket*

18-2526-3536-5051-6465+
Address*
Street Address
Street Address Line 2
Town
County
Postcode
Type of trauma you have experienced/witnessed:*

Domestic AbuseChildhood Sexual AbuseChildhood Physical AbuseMilitary Service or WarPhysical IllnessAccident or DisasterBereavement (whether through death or life)AdoptionMedical EmergencyBullyingChildhood emotional abuseAssaultRapeOther

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.

HomelessnessCare ExperiencedUnemploymentBeen through criminal justice systemPhysical Disability
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.

I have been diagnosed or self-identify as Neurodiverse.
Should you wish to, please use this space to provide more information about the type of neurodiversity you experience.
Should be Empty: