Professional Referral FormPlease note that we only provide our services in North Wales. We aim to respond within three working days. We want to make sure that we are the right service for you. Please confirm that the person you are referring meets our eligibility criteria by confirming the following three options: Adult survivor of childhood sexual abuse that occurred before the age of 18 Lives in North Wales Consent has been given for this referral Has the client accessed our service before? Yes No Not sure Referrer name: * First Name Last Name Job title: * Referral agency: * You email address * Your phone number (###) ### #### Your address Address 1 Address 2 City State/Province Zip/Postal Code Country What is your preferred method of contact? * Email Phone call Text message Letter Local Authority: Ynys Môn Gwynedd Conwy Denbighshire Flintshire Wrexham Client contact details and further information: First Name Last Name Preferred name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email address Phone number (###) ### #### What is the client's preferred method of contact? Email Telephone Letter Text message Client's date of birth MM DD YYYY Client's gender: Female Male Non-Binary Prefer not to say Is client's gender the same as the sex at birth? Yes No How would client describe their ethnicity? Asian or Asian British African Black Black British or Caribbean Mixed or Multiple Ethnic Group White Other Prefer not to say Ethnic group if other Ethnic group if 'other' selected above First language English Welsh Other Is client a Welsh speaker? Yes No Unknown Does client have any criminal convictions? * Yes No If you have selected yes, above, please provide any details of convictions here: Employment status: Employed Retired Student Volunteer Unemployed Do you consider yourself to have a disability or health condition? Yes No Prefer not to say If you have selected 'yes' to having a disability or health condition, above, please provide details here: Service preferences: Do you have any preference as to the gender of your counsellor? Female Male No preference Do you prefer to have a Welsh speaking counsellor? Yes No No preference How would you prefer to access counselling? In person Remotely online Remotely phone No preference We work really hard to meet your service preferences as quickly as possible however, please be aware that very specific requirements may result in a slightly longer waiting time for our service. Additional information: Where did you hear about Stepping Stones North Wales? From my GP From a helpline Google Word of mouth Are you accessing any other services? If yes, please give details below: Thank you for completing this form. The information that you have provided will be reviewed and a member of our team will contact the client within three days to discuss organising the initial assssment.If you have any concerns or questions you can call us on 01978 352 717.
