Pathways to Hope
Referral Form
Name
*
First Name
Last Name
Preferred Name:
Gender
Male
Female
Non-binary
Which set of pronouns would you like to be addressed by?
She/her
He/him
They/them
Other
Email
example@example.com
Telephone Number
*
Date of Birth
*
-
Day
-
Month
Year
Date
Age Bracket
*
18-25
26-35
36-50
51-65
65+
Do you have any access requirements you would like us to be aware of?
How would you prefer us to contact you?
*
Phone
Email
Would you be happy for us to leave a voice message on your telephone?
*
Yes
No
Would you be happy to receive appointment reminders via text?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Other
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
What attracted you to this project?
Do you have a gender preference for your counsellor?
Male
Female
No Preference
Have you had counselling before?
Yes
No
I am aware that Pathways to Hope involves both group wellbeing sessions and 121 therapy and I am able to commit to both.
*
Yes
No
How did you hear about Trauma Healing Together?
Please Select
Internet Search
Support Worker
NHS
Festival
Other service
Friend/family
Social media
Social Worker
Other
Have you accessed our services before?
Yes
No
Which service/organisation?
Is this referral being made for you or on behalf of someone else?
*
Referral is being made on behalf of the above named person
Referral is being made for myself
Referral by other Organisation
Please ensure that the individual being referred is informed of the referral and that your details are filled in below. We are currently facing an issue where many people are unaware of their referrals. Thank you.
Has the person you are referring been made aware of this referral and understands what it involves?
*
Yes
No
Name of person referring (If not self-referral)
First Name
Last Name
Email
example@example.com
Relationship to person being referred
Family/friend
Support Worker
Doctor/Nurse
Other
Additional Information
The information that is provided through the following questions helps us to better understand the challenges experienced by trauma survivors. This section is completely OPTIONAL and you only need to answer if you feel comfortable to do so. The information you provide here will be used for research purposes only and will not impact your ability to use our service.
Have you experienced any of the following?
Homelessness
Care Experienced
Unemployment
Been through criminal justice system
Physical disability
Poverty
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.
Submit
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