Please indicate which Listening Space you require Please indicate which Listening Space you require Knaresborough - Mondays Ripon - Wednesdays Phone - Weekdays between 10am and 5pm

Only complete this form if you are (please tick) ... Only complete this form if you are (please tick) ... Over 18 living within a 20km radius of Ripon Over 18 living outside a 20km radius of Ripon or over 18 and prepared to pay the full cost of therapy

Name

Address

Email Address

Contact Tel No (Is it safe to call and leave a message on this number? )

Is this referral for yourself? Otherwise due to data protection you cannot refer someone else. Is this referral for yourself? Otherwise due to data protection you cannot refer someone else. Yes No

Would you like to be considered for twenty free counselling sessions with a mature university student counsellor? Would you like to be considered for twenty free counselling sessions with a mature university student counsellor? Yes No

What is your age & location (or if on behalf of someone else please give the person's age and location)

Have you historically experienced any of the following Adverse Childhood Experiences (tick all that apply): Have you historically experienced any of the following Adverse Childhood Experiences (tick all that apply): Physical Abuse Sexual Abuse Emotional Abuse Neglect Incarcerated Parents Parental Drug/Alcohol Use

Are you currently experiencing any of the following (tick all that apply): Are you currently experiencing any of the following (tick all that apply): Physical Abuse Sexual Abuse Emotional Abuse Drug/Alcohol Use Eating Disorders Self Harm

Reason for Referral

Have you experienced any medical or birth trauma?

Have you been adopted or in foster care? Have you been adopted or in foster care? Yes No

Are you using: Are you using: Recreational Drugs Class A Drugs Recreational Alcohol None of the Above

Is there any history of mental health issues in the family?

Have you ever been sectioned? Have you ever been sectioned? Yes No

Have you ever attempted suicide? Have you ever attempted suicide? Yes - within the last 12 months Yes - within the last 5 years Yes - within the last 10 years No

Which of the services have you had contact with over the last ten years? (For example Community Mental Health, Police, Probation Service, Fire, Ambulance, Social Services, Hospitals, Child Protection, Safeguarding etc.)

Have you ever been convicted of a criminal offence? Have you ever been convicted of a criminal offence? Yes No

Please tell us if a GP has been involved about the symptoms? Please tell us if a GP has been involved about the symptoms? Yes No

If you answered 'Yes' to the above - please give your GP's details

Trauma is defined as anything that has had a long-lasting negative effect, this can be psychological, physical or emotional; would you consider this to be the case? Trauma is defined as anything that has had a long-lasting negative effect, this can be psychological, physical or emotional; would you consider this to be the case? Yes No

Please tell us what other approaches that have been tried for support (if any)

Would you consider this problem as a safeguarding issue? (high risk of immediate harm) Would you consider this problem as a safeguarding issue? (high risk of immediate harm) Yes No

Please give a brief history of the issue (100 words)

Use of Personal Information (Please tick to confirm) Use of Personal Information (Please tick to confirm) I understand that once submitted my information will be entered into The Wellness Gateway's CRM system which is managed by Kulahub.com and certain staff members will have access to it.

How did you hear about us?

Feeling better and support looks different for everyone, in an ideal world what does the person/you need help with? (100 Words Max) We work with a lot of other organisations as some things are outside our remit, we would refer to this as a holistic person centred approach and want to help and signpost where we can.

Are you in receipt of benefits? Unless you have opted for free sessions with a student, please be aware that sessions are subsidised at £45 each. Evidence of some benefits will discount this cost. Are you in receipt of benefits? Unless you have opted for free sessions with a student, please be aware that sessions are subsidised at £45 each. Evidence of some benefits will discount this cost. Yes No

If yes, which benefits?

Are you currently being supported by secondary care services such as Community Mental Health Teams? If so, please expand on your situation.

If we do offer therapy or counselling it is not ethical for us to support anyone receiving therapy, support or counselling elsewhere (NHS, IAPT, CMHT or private therapy) If we do offer therapy or counselling it is not ethical for us to support anyone receiving therapy, support or counselling elsewhere (NHS, IAPT, CMHT or private therapy) I Understand

Would you like to opt in to our database to receive regular news from us? Would you like to opt in to our database to receive regular news from us? Yes No