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

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

Reason for Referral Reason for ReferralLow MoodAnxietyFeelings of Impending DoomFearDifficulty Coping After a Traumatic EventStress

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

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

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

Have you ever attempted suicide? Have you ever attempted suicide? Yes No

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

Have you ever been convicted of a criminal offence? Have you ever been convicted of a criminal offence? 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.)

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 if a GP has been involved about the symptoms? Please tell us if a GP has been involved about the symptoms? 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 (Please tick to confirm) Access to Personal Records (Please tick to confirm) I understand that in order for RTC to assess my referral, I will be asked to contact my GP, Community Mental Health Teams etc to allow access to my records/diagnoses/interventions/care plans.

Therapy & Assessment Costs (Please tick to confirm) Therapy & Assessment Costs (Please tick to confirm) I understand the full cost of a therapy session is £45 although there is a sliding scale depending on my financial situation.

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 Trauma Centre's CRM system which is managed by Kulahub.com and certain Trauma Centre staff members will have access to it.