Welcome to HSTAR Scotland SCIO External-Referral Form
Our purpose is to support women in rebuilding their lives after experiencing trauma and abuse. HSTAR offers trauma-sensitive, person-centred support to women affected by past trauma, abuse, and mental health challenges. All information provided in this form will be kept confidential and will not be shared outside the charity without your explicit written consent. However, in rare cases where there is a credible risk of harm, we reserve the right to breach confidentiality.
Eligibility
We aim to provide free services to all eligible women in the Forth Valley. However, please be aware that fully funded services may not always be available due to changing funding situations and current projects. If there is no secured funding for the area in which the person you are referring resides, we will offer them the choice of either beginning partially funded sessions or placement on a waiting list. If the person you are referring resides outside the Forth Valley area, we can only offer counselling services on a partially funded basis.
1.
We can accept referrals for women who are over 16 years old, reside in Scotland, and are in a safe personal space/environment. After receiving the referral, we will conduct an intake assessment telephone call with the referred individual within a maximum of 4 weeks. If eligible for our services, the average timeline to be matched with one of our therapists and begin trauma recovery therapy is approximately 6 weeks, depending on the individual’s needs and availability
2.
The referred client may be matched with therapists in training who are completing their placement with HSTAR Scotland. All student therapists are thoroughly screened, insured, registered members of COSCA/BACP, and receive full clinical supervision.
3.
HSTAR Scotland operates a minimum 24-hour cancellation policy. If the client cancels a session with less than 24 hours’ notice or does not attend an appointment, HSTAR Scotland will issue a late cancellation fee of £40, which must be paid before the next session can be booked. HSTAR Scotland provides short-term support (up to 18 therapy sessions; other services may vary). In line with our support model, only two cancellations are permitted within the allocated service block. As a small charity, this cancellation policy is essential to ensure timely communication, enabling us to effectively manage our limited resources and continue offering vital services to those in need. We appreciate your understanding and cooperation.
4.
For therapy and mental health and wellbeing sessions the client will be required weekly attendance; we do not offer flexible or biweekly scheduling options.
5.
Based on our terms and conditions and current funding availability, the client may be required to pay a refundable deposit of £40. This deposit will be returned to the nominated bank account within 14 working days following the client’s final session with our services. Please note, the refundable deposit scheme does not apply to partially funded therapy.
6.
We will offer the client a therapy modality based on their individual healing needs and matched with the availability of a suitable therapist.
7.
While we evaluate each case individually, it may be determined that HSTAR Scotland is not the most suitable option for your client presently. To prevent extended waiting periods and disappointment, kindly consider the following guidelines when referring a client: We may decline or postpone a referral if a woman: - Currently has a complex mental health diagnosis, severe substance abuse issue, or severe eating disorder. - Is not in a safe environment and exhibits risks of self-harm or suicidal tendencies. If you indicate that the client has obsessive thoughts or poses a risk of self-harm or suicide, it is mandatory to provide additional information to the charity detailing the level of risk and how it should be assessed. - Is already undergoing therapy elsewhere. - Is in the midst of an active mental health or neurodiversity diagnostic process. - Seeks counselling to support a legal case or is court-ordered for therapy. - Resides with or is in a relationship with the perpetrator of abuse. - Uses your organisation's email address as this violates our privacy and confidentiality policies regarding external email communications with individuals.
Personal Information of the Referred Individual
Please tell us about the person you are referring to us.
Full Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date Picker Icon
Gender
*
Country of birth/ethnicity?
*
Preferred language
*
Address
*
Street Address
Street Address Line 2
City/town
State
Postcode
Phone number
*
E-mail
*
example@example.com
Would this client consider a male therapist?
*
Yes
No
Emergency contact
Please ask the referred individual to provide us with an emergency contact.
Full Name
*
First Name
Last Name
Their phone number
*
Relation to referred individual
*
Which GP practice are they registered with?
Name of GP Practice
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Reason for referring to HSTAR Scotland
Please select the options below that match their situation.
What services are they interested in?
*
Safety Planning
Mental Health Wellbeing 1-2-1
1-2-1 therapy
CICA and Advocacy support
Group sessions
Coffee and chat
Walking therapy
Workshops
On a scale of 1 to 10, how much has trauma impacted their 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
Could you please tell us why you are referring this client to our services at HSTAR Scotland?
*
Please provide information about any current or past risk for self-harm or suicide. Does this person have any current thoughts of self-harm or suicide? - Has this person attempted suicide in the past 12 weeks? -Please include any other relevant history of risk.
*
Is the referred individual currently taking any prescribed medication or self-medicating? If yes, please specify the medication name and dosage.
*
Do they have a history of any physical and/or mental health difficulties? If yes, please tell us what help/contact they have had with services in the past?
*
In the last 6 months have they received any form of therapy, care or treatment from services for their physical and/or mental health difficulties?
*
Referrer Information
Please provide details about yourself.
Full Name
*
First Name
Last Name
Your phone number
*
E-mail
*
example@example.com
Your Organisation
*
Date
*
/
Day
/
Month
Year
Confidentiality and Privacy
Respecting your confidentiality and privacy is fundamental to our practice. Your form will be stored securely and governed in line with our GDPR. We will not share your information with anyone outside our practice, unless we believe you are at imminent risk of harm (or a child or vulnerable adult is at a serious risk). In this instance we are legally bound to share basic information in order to keep you (or a vulnerable other) safe. *
I have read and I understand this privacy information
*
Yes
Do you have a question you would like us to answer?
Submit
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