Referring Details
Is the referral for you or someone else?
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Please Select
Myself (Self-Referral)
Someone else (External Referral)
In order to continue with this referral please confirm you have permission from the person being referred to make this referral.
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I confirm
In order to continue with this referral please confirm that the referred person is NOT currently receiving any mental health therapy
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I confirm
In order to continue with this referral please confirm that the referred person is NOT currently feeling suicidal, engaging in significant self harm behaviours and can keep themself safe
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I confirm
In order to continue with this referral please confirm that the referred person is NOT currently seeking counselling to support a legal case or is court-ordered for therapy
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I confirm
Name of Referring Organisation
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Name of Person Making this Referral
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Profession/ Job title of Person Making this Referral
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Email address of Person Making this Referral
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Phone Number of Person Making this Referral
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Personal details
Full Name
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First Name
Last Name
Date of Birth
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-
Day
-
Month
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postcode
Gender:
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Please Select
Female
Male
Trans Female
Trans Male
Other
Phone Number
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Email address
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example@example.com
Best way to contact:
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Phone Call
Email
Text message
Other
Can we leave a voicemail and/or text messages?
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Yes
No
Therapy facilitation preferences:
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Face to Face
Online - Zoom
Online - WhatsApp
Phone
Other
Most suitable availability for therapy sessions?
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Monday
9am - 12pm
12pm - 4pm
4pm - 7pm
Tuesday
9am - 12pm
12pm - 4pm
4pm - 7pm
Wednesday
9am - 12pm
12pm - 4pm
4pm - 7pm
Thursday
9am - 12pm
12pm - 4pm
4pm - 7pm
Friday
9am - 12pm
12pm - 4pm
4pm - 7pm
Saturday
9am - 12pm
Preferred Language
*
Female/ Male Therapist perferences
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Please Select
Female
Male
No preferences
Country of birth / ethnicity
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Emergency Contact
Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
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Emergency Contact relationship to the referred person?
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GP Practice Details
Name of GP Practice
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Address of Practice
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Street Address
Street Address Line 2
City
State / Province
Postcode
GP Phone Number
Reason for referral
What does the individual need support with? (tick multiple options, if necessary)
Type of trauma you have experienced/witnessed during childhood:
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Emotional Abuse
Physical Abuse
Sexual Abuse
Other
On a scale of 1 to 10, how much does your trauma impact your life?
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Not at all
1
2
3
4
5
6
7
8
9
Everyday
10
1 is Not at all, 10 is Everyday
What changes could be made through therapy? What would be the therapy goals? What are the expectations from receiving therapy?
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Are you currently taking any medication prescribed by a doctor? If yes, please specify
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Do you have a history of mental health problems? If yes, please tell us what help/contact you have had with services in the past
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Have you received any form of therapy, care or treatment for mental health difficulties in the last 6 months?
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Do you currently use drugs or alcohol? If yes, please give details and amount
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Would the referred person like to learn more about our other supportive services? If, so please let us know which ones:
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Mental Health Wellbeing 1-2-1
Coffee and chat
Safety Planning
Walking therapy
1-2-1 Therapy
Workshops
Group sessions
Resilience and Empowerment Meetings
Resilience and Empowerment Meetings
Other holistic services
How did you hear about this service?
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Newsletter
Facebook
Twitter
Other social media channels
Website
HSTAR Scotland/ SRFCA charity
GP/ Community Link Worker/ MH Nurse
Local Council
Friends/ Word of mouth
Other
If you clicked "Other" above, please let us know how did you hear about this service?
Confidentiality and Privacy
We advise you and your organisation to carefully assess each referred person for our therapy to help mitigate any distress or disappointment. We treat inquiries and counselling discussions as private and confidential. Any information provided will be kept confidential. Information will not be disclosed to anyone outside the charity unless expressly requested in writing. However, in rare cases, we reserve the right to breach confidentiality if there is a credible risk of harm. Respecting your confidentiality and privacy is fundamental to our service. Your form will be encrypted and stored securely in our password protected system and governed by strict GDPR rules. We will not share your information with anyone outside our organisations, 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
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Yes
Contact Information
We wont share your details with anyone outside of our organisations, we will only use your contact details to communicate important information about our services.
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