Contact Forms Archives - A Positive Start CIC

Survivors Speakers Corner EOI

Introduction

Funded by the Volant Charitable Trust, The Survivors Speakers Corner is an in-person supportive safe space for women who have experienced domestic violence, abuse, stalking, coercive control and trauma, centred on safety, choice and dignity.

What You Can Expect

Participants can expect a supportive and respectful space where people are welcome to talk, listen, and connect with others who understand. The group will include opportunities for open conversation, gently facilitated discussions, short, talks, creative activities such as poster creation, and occasional workshops focused on healing, awareness and survivors voices. There is no pressure to speak or participate in any activity - you are free to take part in whatever way feels most comfortable for you.

Confidentiality Agreement

To help create a safe and respectful space for everyone attending the Survivors Speakers Corner, we ask all participants to agree to the following: I understand that personal stories and experiences may be shared within the group. I agree to respect the privacy of others and will not share or repeat any personal information or identifying details discussed during the sessions outside of the group. I understand that this space is built on trust, respect, and confidentiality. This is a safe space for women only.

Name(Required)

First Last

Email(Required)

Phone(Required)

Preferred Contact(Required)

DOB(Required)

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

by Deborah J Crozier

International Counselling Contract

Client Details

Full Name(Required)

First Last

Phone (Including Country Code)(Required)

Date of Birth(Required)

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Emergency Contact/Next of Kin

Name(Required)

First Last

Relationship to Client(Required)

Phone (Including Country Code)(Required)

Alternative Phone

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

GP/Primary Care Provider

Name of GP/Physician(Required)

Name of Clinic/Practice(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Nearest Hospital/Mental Health Service, if known.(Required)

Consent Section

Signature Section

Print Full Name(Required)

by Deborah J Crozier

Counselling Agreement & Client Information Form

1. Client Details

Name

First Last

Date of Birth

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Phone

Preferred Contact Method

Phone

Either

Next of Kin

Next of Kin Phone No.

Next of Kin Relationship

2. GP Details

Name of GP

GP Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

GP Phone No

3. Counselling Agreement

4. Counselling Agreement

I understand that counselling sessions are approximately 60 minutes in duration and that payment is required in advance unless otherwise agreed. As a person-centred therapist and Chartered Fellow Member of the ACCPH, Deborah aims to provide a safe, supportive and non-judgemental environment where I can explore my thoughts, feelings and experiences at a pace that feels comfortable for me. The therapeutic relationship will be based upon empathy, respect, honesty and recognition of my autonomy and personal choice. I understand that information shared within counselling sessions will remain confidential unless there are concerns relating to serious harm, safeguarding, or where disclosure is required by law. Wherever possible, this would be discussed with me first. I understand that I am entering into counselling with A Positive Start CIC under the fee option selected above. I confirm that I have selected the correct counselling option, understand the associated fees, and agree to the counselling agreement and cancellation policy. Counselling sessions are not an emergency service. If you feel at immediate risk or require urgent support, please contact your GP, NHS 24, emergency services, or an appropriate crisis support service

5. Cancellation Policy

I understand that a minimum of 24 hours’ notice is required to cancel or rearrange a session. Sessions cancelled with less than 24 hours’ notice may still be chargeable. If A Positive Start CIC needs to cancel, I will be given as much notice as possible and offered an alternative appointments.

Client Declaration

Client Declaration By typing my full name below, I confirm this acts as my electronic signature and that I agree to the counselling agreement, confidentiality policy, fee agreement and cancellation policy outlined above. Your information will be stored securely in line with GDPR and professional ethical guidelines

Full Name (Electronic Signature)

Date of signature

by Deborah J Crozier

Consent for Sharing Personal Reflections

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Consent for Sharing Personal Reflections As part of the STAND: Parents as Protectors workshop

Throughout the program, you are invited to reflect on and share personal experiences in written form through the accompanying worksheets and questions. These reflections are an optional but meaningful way to support your learning and self-awareness.

By ticking the box and signing below, you acknowledge and consent to the following:(Required)

I understand that the information I choose to share in my worksheets and questions may include sensitive personal experiences.

I give my consent for this information to be accessed solely by the program facilitator/s for the purpose of supporting my learning with this trauma-informed programme.

I understand that my personal reflections will be held in strict confidence, in accordance with GDPR and ethical good practice.

I understand that this information will not be shared with third parties, used for marketing, or included in any reports or publications without my explicit written permission.

I understand that I may withdraw my consent at any time, without needing to provide a reason, and without any impact on my participation in the programme.

All of the Above

Important Note:

If you prefer not to submit your completed worksheets, you are welcome to maintain your privacy. Instead, you may choose to write a brief anonymised statement at the end of each module summarising what you have learned and how it applies to your role or experience. These statements will be assessed using the same learning criteria and with equal respect for your contribution. This declaration ensures your reflections are handled with respect, care, integrity, and trauma-informed sensitivity – because your voice, your choice, your boundaries, and learning journey matter.

Name(Required)

First Last

Date(Required)

by Deborah J Crozier

Survivors Voices Cafe

Introduction

What You Can Expect

Confidentiality Agreement

Name(Required)

First Last

Email(Required)

Phone(Required)

Preferred Contact(Required)

DOB(Required)

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

by Deborah J Crozier

Contact Forms

Introduction

What You Can Expect

Confidentiality Agreement

Client Details

Emergency Contact/Next of Kin

GP/Primary Care Provider

Consent Section

Signature Section

1. Client Details

2. GP Details

3. Counselling Agreement

Client Declaration

Partner referrals are reviewed within two working days. Placements are confirmed once suitability is agreed and payment has been received.

Section 1: Referring Organisation Details

Section 2: Client Details

Section 3: Reason for Referral

Section 4: Support Context

Section 5: Risk Awareness

Section 6: Availability

Section 7: Funding Agreement

Section 8: Consent to Share Information

Section 9: Additional Information

Consent for Sharing Personal Reflections As part of the STAND: Parents as Protectors workshop

Important Note:

Book a Free 30-Minute Initial Consultation Call

Section 1: Contact Details

Section 2: Availability for Your Consultation Call

Section 3: What Support Are You Looking For?

Section 4: How would you like to begin counselling?

Section 5: Student Counsellor Suitability

Section 6: Age Confirmation

Section 7: Consent to Contact

Section 8: Optional Practical Information

Thank you for completing your self-referral form.

Who This Form Is For

Section 1: Referrer Details

Section 2: Client Details

Section 3: Consent

Section 4: Reason for Referral

Section 5: Risk & Suitability Screening

Section 6: Practical Information

Thank you for your referral. Referrals are reviewed to determine suitability for student counsellor placement support. Where student provision is not appropriate or available, we will advise on alternative options including our reduced partner-rate counselling pathway.

Introduction

Referrer Details

Client Details

Primary reason for referral

Suitability Screening

Safeguarding

Consent and Information sharing

Contact Preferences

Additional Information

Submission Statement

Introduction

Contact Information

Retreat Enquiry

Interest During the Retreat

Your Retreat Intentions

Practical Information

Consultation Consent

Introduction

What You Can Expect

Confidentiality Agreement