Please read before you fill out this form:
Our free of charge trauma recovery counselling is currently available to Forth Valley residents only. If you reside outside the Forth Valley area we are unable to cover the full costs of therapy. Our therapy will be offered at reduced charity rate of £30 per hour, and HSTAR will take responsibility of remaining costs of services. We understand that this may still be a significant expense for some individuals. However, until we secure additional funding, we regretfully cannot extend our free therapy support to women residing outside the Forth Valley.
Self-Referral Form
Welcome to HSTAR Scotland Self-Referral Form. If you would like to see one of our therapists, please let us know by completing the below form. Our 8-hours free counselling is available to women aged 16 and over, who are residing in Scotland and are in a safe place. You will hear from a member of our administration team within three working days after you submit the online referral form. We may decide to turn down or postpone a referral if a woman: • has a current complex mental health diagnosis, severe substance abuse issue or severe eating disorder. • is seeking counselling in order to support a court case or is court-mandated for therapy. • is currently living with a perpetrator of domestic or sexual abuse.
Refundable Deposit
We take a fully refundable deposit of £30 for all our services, even thou all our supportive activities are free of charge. Once you attended your 8-free sessions HSTAR will send to you the deposit request form. Your deposit will be refunded directly to your bank account within 2 working days from the last session of our services. Refundable deposit scheme for paid clients is not applicable.
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
Therapists in Training
It is common practice for third sector organisations to enlist the assistance of student therapists. It is not unsafe due to the fact that the students' fitness for practice is assessed at the start of their studies. Students are supervised by their supervisors, who are ultimately responsible for ensuring the client's wellbeing. A supervisor is a fully qualified and experienced therapist.
In order to continue with this referral please tick to confirm that you accept to be receiving therapy from fully supervised Therapist in Training * 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. For more information, please contact your general practitioner. 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
Type option 4
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
What are the current problems you would like to work on?*
*
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 Domestic Abuse
Mental Health Wellbeing 1-2-1 support (Stirling)
Mental Health Wellbeing 1-2-1 support (Glasgow)
Mental Health Wellbeing group sessions (Stirling)
Mental Health Wellbeing group sessions (Glasgow)
Art and creativity sessions in Stirling
Art and creativity sessions in Glasgow
Advocacy Clinic
Befriending Services
Mindfulness and Meditation Group Sessions in Stirling
Mindfulness and Meditation Group Sessions in Glasgow
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.
Do you have a question you would like us to answer?
Submit
Print Form
Should be Empty: