We want to make sure that we are the right service for you. Please confirm that you meet our eligibility criteria by confirming the following three options: Adult survivor of childhood sexual abuse that occurred before the age of 18 Live in North Wales Consent has been given for this referral Have you accessed our service before? Yes No Not sure About you: * First Name Last Name Preferred name * Previous surname (if applicable) 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 Your date of birth * MM DD YYYY Your GP's name (if known): Name of your GP's practice / surgery: Your GP's address line 1 Your GP's address line 2 Your GP's postcode Your GP's phone number Are you accessing any other services? If yes, please give details below: Do you have any criminal convictions? * Yes No If you have selected yes, above, please provide any details of convictions 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: Your gender: Female Male Non-Binary Prefer not to say Is your gender the same as the sex assigned at birth? Yes No Prefer not to say How would you describe your 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 First language English Welsh Other 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: Employment status: Employed Retired Student Volunteer Unemployed Where did you hear about Stepping Stones North Wales? From my GP From a helpline Google Word of mouth Thank you for completing this form. The information that you have provided will be reviewed and a member of our team will reply to you within three days to discuss organising your initial assssment.If you have any concerns or questions you can call us on 01978 352 717. Self Referral FormPlease note that we only provide our services in North Wales. We aim to respond to you within three working days.
