Welcome to HSTAR Scotland Self-Referral Form
Our purpose is to help women to rebuild their lives after the harm done through trauma and abuse. Our organisation provides trauma-sensitive and person-centred support to women suffering from past trauma, abuse, and mental health issues.
Please read before you fill out this form:
At HSTAR Scotland, 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.
Forth Valley residents
We aim to provide free trauma-informed and trauma-responsive therapy to all eligible women in the Forth Valley. Please be aware that free counselling may not always be available due to the current funding situation of the charity. If there is no secured funding for residents of the Forth Valley area, we will give you the option of either partially funded sessions or being placed on a waiting list.
Out of Forth Valley residents
If you reside outside the Forth Valley area, HSTAR Scotland can only offer partially funded therapy. Following the intake assessment and confirmation of eligibility, we can offer up to 18 therapy sessions at a reduced charity rate of £30 per hour. HSTAR will cover the remaining costs of services and management expenses. We acknowledge that this cost may still be significant for you, but HSTAR Scotland needs to protect its own sustainability as well.
1.
We can accept referral from women who are over 16 years old, reside in Scotland, and who are in a safe personal space/ environment. The average waiting time from receiving a referral to the first therapy session maybe up to 6 weeks, with the Intake Assessment call scheduled within 4 weeks of the referral date.
2.
You may be matched with therapists in training who are undertaking their placement with HSTAR Scotland. All our students are thoroughly screened, insured, members of COSCA/BACP, and receive complete supervision.
3.
We enforce a Late Cancellation policy of 24 hours; if a cancellation is made with less than 24 hours' notice, HSTAR will invoice the client £30. HSTAR Scotland provides short-term therapy (up to 18 sessions) and as per our guidelines, only 2 cancellations are permitted within the allotted therapy block.
4.
You will be required to schedule weekly sessions; we do not offer flexible or biweekly scheduling options.
5.
For clients eligible for free therapy, we require are fundable deposit of £30. This deposit will be returned to the nominated bank account within 14 working days following the last session of our services. The refundable deposit scheme does not apply to partially funded therapy.
6.
We will offer you a therapy modality based on your individual healing needs and matched with the potential therapist availability.
7.
We will be contacting you via email or telephone during your engagement with HSTAR in case of anything what is relevant to your therapy with us. We would expect your to reply to our emails or returning our calls within maximum 5 working days, we might close your file if you remain unresponsive.
Receiving a therapy elsewhere
You should not be receiving any other counselling support at the time of self-referral, you must notify us about any ongoing medical treatment about your physical and mental health wellbeing. Working with our women requires ensuring they are not receiving therapy, mental health treatment, or health care from another mental health professional, otherwise they may receive inadequate or harmful treatment. This is why HSTAR asks every potential client if this is the case.
In order to continue with this referral please tick to confirm that you are NOT currently receiving any other counselling therapy, mental health treatment * I confirm
*
Yes
SELF HARM / SUICIDAL RISK
You should not use this service if you are suicidal, engaging in significant self-harm, or unable to keep yourself safe. Emergency Contact Information. If your mood deteriorates and you need urgent help please contact one of the following: - GP ‘out of hours' service, 111 who can put you through to an out of hours doctor or help if necessary. - Samaritans: Telephone support, Tel. 116 123 Hours: 24 hours, 7 days a week Samaritans website: www.samaritans.org or - In an extreme emergency call 999 for an ambulance or go to the nearest Emergency Department.- Your GP in surgery hours;
In order to continue with this referral please tick to confirm that you are NOT currently feeling suicidal or engage in significant self harm behaviours and can keep yourself safe * I confirm
*
Yes
Shall we be aware of any safety risk? Our trauma recovery therapies are not emergency or intervention services. If you were at risk of self-harm or suicidal thoughts/attempts within the last 12 weeks, we might not be able to assist you.
*
Personal Information
Please tell us a little bit about yourself
Full Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date Picker Icon
Address
*
Street Address
Street Address Line 2
City/town
State
Postcode
Phone number
*
National Insurance Number
*
E-mail
*
example@example.com
How would you prefer us to contact you?
*
Phone Call
Text Message
Email
Other
Would you be happy for us to leave a voice message on your telephone?
*
Yes
No
Our therapists working hours are: Monday - Friday 9am - 4pm. However we may try to allocate a therapy online between 4pm - 7pm (very low availability, and waiting time can take longer). Please share your availability for therapy.
*
Monday 9am -12pm
Monday 12pm - 4pm
Tuesday 9am -12pm
Tuesday 12pm - 4pm
Wednesday 9am -12pm
Wednesday 12pm - 4pm
Thursday 9am -12pm
Thursday 12pm - 4pm
Friday 9am - 12pm
Friday 12pm - 4pm
Monday - Friday 4pm - 7pm ONLINE THERAPY ONLY
Other
Would you consider a male therapist?
*
Yes
No
Preferred language
*
Country of birth/ethnicity?
Emergency contact
Full Name
*
First Name
Last Name
Their phone number
*
Relation to you
*
Which GP practice are you registered with?
Name of GP Practice
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for contacting HSTAR Scotland
Please select the options below that match your situation.
Type of trauma you have experienced/witnessed:
*
Domestic Abuse
Sexual Abuse
Childhood Emotional Abuse
Childhood Physical Abuse
Childhood Sexual Abuse
Terrorist Attack / War
Ethnicity
Religion / Faith
Gender/ Sexuality
Bereavement
Adoption / Social Care
Bullying
Health/ Medical Condition
Assault
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
Please state the changes you would like to make through therapy and the reasons for doing this now?
*
Are you currently taking any medication prescribed by a doctor?* If yes, please specify
*
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
*
Have been in the last 6 months receiving any form of therapy, care or treatment from services for your mental health difficulties*
*
Do you currently use drugs or alcohol?* If Yes, please give details and amount
*
How did you hear about the service?
*
Our Other Supportive Services
Our objective is to advance emotional and mental health well-being through the provision of responsive multicultural and multilingual counselling support for women who have been affected by trauma. We are promoting mental health care awareness, hosting multicultural events, delivering focused training, offering befriending activities, and other mental health wellbeing support programmes. It is the main goal of our service to assist you as a woman in exploring and understanding your recovery. You can reclaim your life reactions, and responses in this period of emotional upheaval, anxiety, and despair. All so that you can re-establish your sense of inner balance, perspective, and purpose. We can provide a confidential and supportive space in which calm reflection will enable you to take stock of your experiences, feelings, thoughts, and sensations.Our emotional support practitioners can offer a safe and empathetic space to express - usually online or by telephone - their thoughts and feelings about issues that confront them. It is not about giving our ladies advice or telling them how to be. Rather, the service is designed to help them explore what has happened, what they are experiencing and how they can rebuild their inner strength and self-confidence.
Would you like to learn more about our other supportive services? If, so please let us know which ones:
Criminal Injuries Compensation - CICA scheme for victims of Assault / Abuse
Mental Health Wellbeing 1-2-1 (Stirling)
Mental Health Wellbeing 1-2-1 (online)
Mental Health Wellbeing group (Stirling)
Mental Health Wellbeing group (online)
Art and creativity sessions in Stirling
Advocacy Clinic
Coffee and Chat Group Meetups in Stirling
Confidentiality and Privacy
Respecting your confidentiality and privacy is fundamental to our practice. Your form will be stored securely in our password protected system and governed by strict GDPR rules. If you book in with one of our therapists they will read your referral form before your initial session. 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
Contact Information
We will share your details with your therapist only, and we will use your email to communicate important information about our service, such as appointment times and questionnaires to be completed prior to your appointments. We do not use your email address for any other purpose and never sell your information to any third party.
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