Pathways to Hope Referral Form

Pathways to Hope

Referral Form
Name

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

Other
Email
example@example.com
Telephone Number
Date of Birth

DayMonthYear
Date
Age Bracket
Do you have any access requirements you would like us to be aware of?
Please note, we are on the first floor and there is no step-free access. Due to health and safety, anyone being referred must be able to get up and down the stairs independently. We understand this is a barrier to accessing support, and we are actively looking at options to make our premises more accessible.
How would you prefer us to contact you?
Would you be happy for us to leave a voice message on your telephone?
Would you be happy to receive appointment reminders via text?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of trauma you have experienced/witnessed:

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

1 is Not at all, 10 is Every day

What attracted you to this project?
Do you have a gender preference for your counsellor?
Have you had counselling before?
As part of Pathways to Hope, you attend 14 group wellbeing sessions. These are on set days at times which are likely to be Tuesdays from 10:30am-12:30pm, and Thursdays from 12:30pm-2:30pm. These are mandatory as part of Pathways to Hope and we cannot offer standalone counselling.
Knowing the above information, I am aware that Pathways to Hope involves both group wellbeing sessions and 121 therapy and I am able to commit to both.
How did you hear about Trauma Healing Together?
Have you accessed our services before?
Which service/organisation?
Is this referral being made for you or on behalf of someone else?
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?
Name of person referring (If not self-referral)

First NameLast Name
Email
example@example.com
Relationship to person being referred

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?
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.
We may be running a Pathways to Hope programme for Women from Diverse Ethnic Communities. If this is running, would you be interested in referring to this too?
Should be Empty:

Pathways to Hope

Referral by other Organisation

Additional Information