Only complete this form if you are (please tick) ... Only complete this form if you are (please tick) ... Under 18 living in an HG postcode Under 18 living outside the HG postcode 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 your enquiry... Is your enquiry... For yourself For a family member For a friend A referral

Are you wanting a place with a student? Are you wanting a place with a student? 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 Reason for ReferralLow MoodAnxietyFeelings of Impending DoomFearDifficulty Coping After a Traumatic EventStress

Have you experience any medical or birth trauma?

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 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

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)

Access to Personal Records (OVER 18's ONLY - Please tick to confirm) Access to Personal Records (OVER 18's ONLY - Please tick to confirm) I agree that before The Wellness Gateway assess my referral they may need me to contact my GP and give permission for my GP to send a brief medical history by email to The Wellness Gateway at contact@thewellnessgateway.org

Access to Personal Records (OVER 18's ONLY - Please tick to confirm) Access to Personal Records (OVER 18's ONLY - Please tick to confirm) I agree that before The Wellness Gateway assess my referral, if I have received any Community Mental Health Support they need me to contact those teams and give permission for them to send a brief mental health history to The Wellness Gateway at contact@thewellnessgateway.org

Therapy & Assessment Costs (Please tick to confirm) Therapy & Assessment Costs (Please tick to confirm) I understand the full cost of a 90 minute adult therapy session is £90 or a 60 minute under 18's (non HG postcode) therapy session is £45 (although for under 18's there is a sliding scale depending on my financial situation (minimum charge £20/hr).

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.