Pathways to Hope Referral Form

Pathways to Hope

Referral Form
Name*

First NameLast Name
Preferred Name:
Gender
She/herHe/himThey/themOther
Email
example@example.com
Telephone Number*
Date of Birth*

DayMonthYear
Date
18-2526-3536-5051-6565+
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?*
YesNo
YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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?
MaleFemaleNo Preference
YesNo
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.
YesNo
How did you hear about Trauma Healing Together?
YesNo
Which service/organisation?
Referral is being made on behalf of the above named personReferral is being made for myself
I understand that due to a high volume of referrals, Pathways to Hope has a large waitlist, may take longer than usual to make contact, and cannot guarantee a timeframe for response. Thank you for your patience.
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.
YesNo
Name of person referring (If not self-referral)

First NameLast Name
Email
example@example.com
Family/friendSupport WorkerDoctor/NurseOther
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.
HomelessnessCare ExperiencedUnemploymentBeen through criminal justice systemPhysical disabilityPovertyPrefer not to answer
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.
YesNo
Should be Empty:

Pathways to Hope

Referral by other Organisation

Additional Information