STARS - Referral Form

About You

1 First Name *

2 Last Name *

3 How do you like to be addressed?

4 Address line 1 *

5 Address line 2

6 Address line 3

7 Town/City *

8 Postcode *

9 Safe to post to the this address? *

Yes

Contact

Only supply contact information that is safe for us to use. Please supply at least one contact method

10 Mobile Number *

Preferred contact method *

Yes

Safe to leave voice mail *

Yes

11 Phone Number *

Preferred contact method *

Yes

12 Email *

Preferred contact method *

Yes

Safe to email you? *

Yes

More Information

13 Date of Birth *

Age *

14What are your preferred pronouns? *

15 What best describes your ethnic group or background? *

16 What gender do you identify as? *

17 Do you have a trans history? *

18 What best describes your sexual orientation? *

19 GP name & surgery *

20 Have you previously or are you currently being supported by any other agencies? (What support, Who, How Often, Address/contact details) *

Support Needs

Please note that for our Counselling Services, you will need to be at least 12 months free from using substances or alcohol and at least 6 months since any previous attempts on your life or incidents of self-harm. This will enable you to get the most from your therapy. However, our ISVA services are able to support anyone within those categories and someone at STARS will review your request to be referred and advise of what support we can offer.

Mental Health Issues

Substance/Alcohol misuse

Self Harm Issues

Suicide Ideation

If ANY are non recent or current, please give details (when and for how long) or otherwise put in N/A. *

22 Please tell us specifically about any prescribed medication you are on and what it is for ? (if none, please put in N/A) *

23Do you have any additional needs? For example a physical disability or learning/communication needs. *

24Do you have a Social Worker?

Yes

25Are there any children under 18 years of age who live at your property?

Yes

In this next section we will ask you about the reasons why you are seeking support from STARS. Please note you do not have to report to the police to receive support from us.

26Please give a brief explanation of why you are seeking support from STARS. *

27Have you reported anything to the police? *

28 When did the offence take place? *

29 What location did the offence take place? *

30 Where did the offence take place? *

31 How did you know the person who harmed you? *

32 What gender did they present as? *

Safety

Please tell us about your safety:

33Is the person who harmed you aware of where you live? *

Yes

34 Do they still contact you? *

Yes

35Were you / are you living within a domestically abusive relationship? *

36 Are you working with a Domestic Abuse Agency ? If so please state which one and any contact details.

Self Online Referral Form

Please complete this form to be considered as a referral for yourself. Review our privacy policy here.

About You

Contact

More Information

Support Needs

Safety