Kinergy Referral Form

INTRODUCTION

About Us

Kinergy is a charity offering support through specialist, trauma-informed counselling and therapeutic groups to people of all genders aged 18 and over. Our services are offered to anyone who lives in Bristol, South Gloucestershire, BANES and North Somerset who have experienced any form of sexual abuse or violence during their life.

Important Information

Please note that if you have had counselling with us in the last 12 months, we will not be able to accept a referral. Please wait 12 months from your last session.
If you move out of our service delivery area whilst on the waiting list/during your sessions we will no longer be able to continue to offer our services.
Please update us if your contact details change. If we are unable to make contact with you, you will be removed from the waiting list.
If you are completing this form on someone else’s behalf, consent must be obtained.
If there is missing information we may return the referral.

Please answer the following questions as completely as possible.
We understand that some of the questions are quite personal and want to assure you that all data provided will be stored within our secure records system which has the highest levels of security.

At the bottom of this form is a blue button you must click to submit the information.

About the Referrer

Referrer's name

Organisation name

Referrer's phone

Referrer's email

Referrer - Organisation/ Relationship

Self-referral

Yes

How did you hear about us?

How did you hear...? (Other)

About the new client

First Name

Last Name

Date of birth

In format DD/MM/YYYY

Preferred email

Must be a valid email

Preferred phone

Mailing Street

Mailing City

Mailing Zip/Postal Code

How can we contact you?

Email	Phone
Text	Post

Select all that apply

Can we leave a voicemail/message?

Preferred method of contact

About the services requested

We offer 1:1 Counselling and also Group support / Group therapy, as described below. If you are interested in groups please indicate which group (range of options change from time to time).

Do you want to join the waiting list for Counselling?

1:1 Counselling

You can also select Group Support / Group Therapy, tick relevant box if interested...

Group option:

Wellbeing GroupOnline group (3 weeks) that provides support, wellbeing advice and a chance to connect with others. Small, mixed gender groups. Suitable for anybody on the waiting list for 1:1 counselling and/or other group therapy.

Have you had counselling with Kinergy before?

If so, date prior support ended

Reason for referral to Kinergy

Recent sexual violence (last 12 months)

Non-recent sexual violence, (more than a year ago)

Prefer not to say

Unknown

Was this a single incident or have you had multiple experiences?

Did this experience or experiences occur in childhood or adulthood?

ChildhoodAdulthoodPrefer not to sayUnknownTick all that apply

What is/was the perpetrator/s relationship to you?

Have any of the incidents been reported to the police?

Accessing Our Services

Disability, other

Do you feel comfortable and able to walk up stairs?

Do you require wheelchair access?

Any additional information that may be useful / relevant to this referral:

Equalities monitoring

Gender

Do you identify as transgender?

Preferred pronouns

Sexual Orientation

Ethnicity

Religion

Thank you very much for the referral, our team will be in touch shortly.

WHAT TO EXPECT

Once we have received your referral it will be processed within 5 working days and you will receive an email or text confirmation along with an estimate of how long our current waiting time is. When you have reached the top of the waiting list you will be contacted to arrange an assessment.

If you are looking for some support before we are able offer our services, here are some organisations to contact:

Contact your local GP or the NHS helpline on 111
NHS Mental Health crisis line 0800 953 1919 (open 24 hours a day, every day)
Samaritans Bristol 116 123 (Freephone).
SARSAS helplines: 0808 801 0456 or 0808 801 0464
Womankind helpline number for women: 0117 9166461 or 0345 458 2914

Equality and Diversity

Kinergy actively promotes equality and diversity and is committed to providing a safe environment and fair treatment of all clients and staff. As such, we do not tolerate any form of discrimination, and reserve the right to terminate your counselling should discriminatory language, attitudes or behaviour be used. If you feel you have been discriminated against please follow our complaints procedure. Kinergy takes all complaints seriously and follows due process.