Self-Referral Form

Book a Free 30-Minute Initial Consultation Call

Thank you for getting in touch with A Positive Start CIC. The first step is a free 30-minute telephone consultation, where we can learn a little about what you’re looking for and explore the best support options together. Please complete the short form below and we’ll email you to confirm an appointment time.

Section 1: Contact Details

Name(Required)
MM slash DD slash YYYY
Preferred Contact Method(Required)
Is it appropriate to leave a voicemail?(Required)

Section 2: Availability for Your Consultation Call

Please let us know two or three preferred days/times for your 30-minute consultation:
Preferred Day/Time Option

Section 3: What Support Are You Looking For?

Type of Support Requested(Required)
If EFT, What would you most like support with through EFT?
Previous Counselling Experience(Required)

Section 4: Fee Band Selection

Which fee level feels right for you?
Options(Required)

Section 5: Student Counsellor Suitability

Would you be open to working with a supervised student counsellor if appropriate?
Options(Required)

Section 6: Age Confirmation

Are you aged 18 or over?
Options(Required)

Section 7: Consent to Contact

Consent Statement
I understand the first step is a free 30-minute consultation call and consent to be contacted to arranged this.(Required)

Section 8: Optional Practical Information

Thank you for completing your self-referral form.

The first step is a free 30-minute telephone consultation, where we can explore what has brought you to seek support and consider the most appropriate options together. A member of our team will review your form and contact you by email to confirm a suitable appointment time, usually within 2–3 working days. If your situation becomes urgent while you are waiting to hear from us, please contact your GP or local crisis support services. We look forward to speaking with you

Children & Families Social Work referrals

Who This Form Is For

This form is for Children & Families Social Work referrals requesting access to supervised adult (18+) student counsellor support at A Positive Start CIC .

Section 1: Referrer Details

Name(Required)

Section 2: Client Details

Client Name(Required)
MM slash DD slash YYYY
Preferred Contact Method(Required)
Safe to leave voicemail?(Required)

Section 3: Consent

Section 4: Reason for Referral

Section 5: Risk & Suitability Screening

Is the client currently experiencing: (Tick All that Apply)(Required)
Are you aware of any current involvement from statutory mental health services?(Required)

Section 6: Practical Information

Preferred session format

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.


APS Early Intervention Craving Pathway™ Referral

This field is for validation purposes and should be left unchanged.

Introduction

This referral form is intended for professionals referring individuals into the APS Early Intervention Craving Pathway™. The pathway supports adults experiencing stress-related coping behaviours involving alcohol, cannabis, smoking, chocolate, or other non-dependent substance or behavioural cravings. Referrals should only be made where informed consent has been obtained from the individual and a brief telephone consultation with the referrer has taken place to confirm suitability.

Referrer Details

Referrer Name(Required)

Client Details

Primary reason for referral

Options(Required)
Brief summary of emotional triggers, coping behaviours, and current difficulties.

Suitability Screening

Current pattern appears to be:(Required)
Client appears suitable for outpatient therapeutic support
Please tick all that apply
Is there evidence of any of the following?(Required)

Safeguarding

Are there current safeguarding concerns?(Required)

Consent and Information sharing

Client consent Confirmation(Required)
I confirm that the client has given informed consent for this referral and understands that their information will be shared with A Positive Start CIC for the purpose o accessing the APS Early Intervention Craving Pathway™
Consent to share progress update with referrer(Required)

Contact Preferences

Preferred contact route for client(Required)

Additional Information

Please include only information relevant to referral suitability and support planning.

Submission Statement


Start Your Retreat Enquiry

Introduction

Thank you for your interest in the River Room Rest & Reset Retreat. This short form allows us to learn a little about you before arranging a free initial consultation The consultation helps us ensure the retreat is suitable and allows us to shape the experience around you needs. All information share here will be treated with care and confidentiality.

Contact Information

Name(Required)
Preferred Contact Method(Required)

Retreat Enquiry

Are you enquiring for(Required)
Which option best describes your interest?(Required)

Interest During the Retreat

Which types of support interest you?(Required)

Your Retreat Intentions

Practical Information

Will you be travelling by car?(Required)

Consultation Consent

I understand that:(Required)

Survivors Voices Cafe

Introduction

The Survivors Voices Cafe is a supportive space for adults who have experienced abuse or trauma. The cafe is hosted by Sebastian Etienne and supported by Deborah J Crozier, Trauma-Informed Practitioner and Founder of A Positive Start CIC. It offers a calm, respectful environment where survivors can connect with others who understand. There is no pressure to speak - you are welcome to simply listen and be present.

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 cafe 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 survivor voice. 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 Voices Cafe, 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 cafe outside of the group. I understand that this space is built on trust, respect, and confidentiality.
Name(Required)
MM slash DD slash YYYY
Address

End of Therapy Review and Closure

Section 1 - About Your Support

Choose from the dropdown options

Section 2. What Has Changed?

On a SUD (subjective units of distress) Scale of between 0-10
On a SUD (subjective units of distress) Scale of between 0-10
Choose one answer from the dropdown that best describes you experience.

Section 3. You Experience of Therapy

On a Scale of 1. Strongly Agree > Strongly Disagree
11. My therapist was:
(Tick all that apply)
On a Scale of 1. Strongly Agree > Strongly Disagree
Choose one

Section 4. Service Feedback

Choose one

Section 5. Closure Confirmation

18. I understand my therapy sessions have now ended.(Required)
19. I know I can contact A Positive Start CIC in the future if i need further support.(Required)
On a Scale of 5. Very Satisfied > 1. Very Dissatisfied

Thank you

Thank you for taking the time to complete this reflection. Your voice matters to us, and your feedback helps us continue creating safe, compassionate spaces for others. We wish you continued growth, strength, and gentleness with yourself as you move forward. With warmth, A Positive Start CIC

Practicum Student/Student Placement Application Form

This field is for validation purposes and should be left unchanged.

A Positive Start Student Placement Application

Thank you for your interest in a student placement with A Positive Start CIC. We are a trauma-informed, person-centred organisation supporting community wellbeing through counselling, education, and relational safety. This form helps us understand your training requirements, readiness for placement, and how we can support you safely and ethically. Completion Time Approx: 10 - 15 mins. If you need adjustments to complete this form, please email Deborah at info@apositivestart.org.uk

Your Details

Name(Required)
Address(Required)
Email(Required)

Your Provider

Who are you studying with?
Name of course provider
How many years are you studying over?

Regarding Placement

Trauma Awareness & Understanding

3000 characters

Emotional Regulation & Self-Awareness

3000 characters

Reflective Capacity

3000 characters

Supervisor Details

A Positive Start CIC we will provide ongoing support and guidance, however you are also required to have your own supervisor outside of the placement.
Name

References

Referee 1

This should be your tutor or course provider
1. Name(Required)
Address(Required)
Email(Required)

Referee 2

This should be someone who knows you personally
Name(Required)
Address(Required)
(Preferred)
(if known)
What days are you available?(Required)
What times are you available?(Required)

Thank You

Thank you for considering A Positive Start CUC for your placement. We truly appreciate your interest in the work we do and the values we hold. We wish you every success in your studies and in the continued development of your practice. It is always a privilege to support students as they grow in confidence, knowledge, and professional presence. We are delighted to play a small part in your journey and to support the development of the next generation of trauma-informed practitioners, who will go on to create safer, more compassionate spaces for those they work with.

Participant Consent Form

Study Details

Exploring Emotional Freedom Techniques (EFT) for Supporting Cravings and Emotional Regulation Researcher: Deborah J Crozier University: UWS Course: MSc Contemporary Drug & Alcohol Studies

Overview of Consent

You are being invited to take part in a small research study exploring whether a simple self-help technique called Emotional Freedom Techniques (EFT) may support people in managing cravings and emotional responses related to substance use. Before deciding whether to take part, it is important that you understand what participation involves. If you agree to take part: You will be invited to attend up to four EFT sessions focused on understanding and managing cravings and emotional regulation. You will be asked to complete very simple rating questions (for example, rating cravings or how settled you feel) before and after sessions. You may be invited to complete a short feedback form at the end of the sessions. Participation is completely voluntary. You are free to stop taking part at any time without giving a reason. Taking part will not affect any services or support you currently receive. EFT is a supportive technique, not a medical or addiction treatment. Your information will be treated as confidential and anonymised. Your name will not appear in any report. If there are serious concerns about safety or risk of harm, confidentiality may need to be broken in line with safeguarding responsibilities. Please take time to read the statements in the consent section carefully before signing. If anything is unclear, you are encouraged to ask questions before deciding whether to participate.
Please read each statement carefully and tick to confirm

Participant Details

Name
How would you like to be contacted to discuss taking part in this in-person study?
MM slash DD slash YYYY

Host Us

Host Us

Bring Emotional Safety, Body Confidence & Regulation To Your Children At A Positive Start CIC, we work with schools, nurseries, community groups and organisations to support children’s emotional wellbeing, confidence and safety through music-based, trauma-informed learning. If you would like to invite The River Room Songbook and My Body Is My Body programme to your school, setting or community — we would love to hear from you.

What We Offer

We deliver gentle, engaging sessions for: Nurseries & Early Years Primary Schools Community & Family Groups Parent Workshops Professional / Staff Sessions Our sessions combine: 🌊 Emotional regulation through music 🛡 Body safety & confidence (MBIMB) 🌿 Nervous system calming tools 🎵 Interactive songs & movement 🤝 Parent & staff guidance

Who We Are

Who We Are Deborah J Crozier Founder — A Positive Start CIC MBIMB Ambassador & Board Member Lesley Redshaw and Stephanie Davies - APS CIC Volunteers A Positive Start CIC are official partners bringing My Body Is My Body to Scotland, helping children learn body confidence, safety and how to use their voice. Our safeguarding work is supported by the NSPCC.

Invite Us To Your Area

We can visit: Schools Nurseries Community centres Family hubs Events Training settings Sessions can be tailored for: ✔ Age group ✔ Setting size ✔ Parent involvement ✔ Staff training

How To Invite Us

Please complete the Host a Session Form below and we will contact you to discuss: Your setting Age group Group size Location Possible dates Your needs and goals We aim to respond within 3–5 working days.

Basic Details

Name(Required)
Please choose from the following options
Location(Required)

Practical Info

Indoor Space Available?
Equipment Available?

Counselling Agreement and Information Sharing Consent

Purpose of Counselling

Counselling provides a supportive, confidential space to explore emotional wellbeing, life experiences, challenges, and coping strategies. The aims of counselling include: *Supporting emotional understanding and regulation *Encouraging healing and personal growth *Strengthening coping strategies *Enhancing wellbeing and stability *Supporting safer, healthier relationships Counselling is a collaborative process and works best when both client and therapist engage openly and respectfully.

Therapist Role and Approach

Your therapist works using a trauma-informed, person-centred approach that is: *Respectful and non-judgemental *Boundaried and professional *Focused on emotional safety *Supportive of autonomy and empowerment The therapist does not replace medical, legal, or social care services, but may work alongside other professionals where appropriate.

Safeguarding Commitment

The safety and wellbeing of clients, children, vulnerable people, and the wider community is a priority. This means: *Counselling will always prioritise harm prevention and safety *Behaviour that places yourself or others at risk will not be supported or encouraged *Safeguarding procedures will be followed when required Safeguarding is about protection, care, and prevention - not punishment.

Confidentiality and It's Limits

What you share in counselling is treated with respect and confidentiality within legal and ethical boundaries. Confidentiality may be broken if: *There is serious risk of harm to you or others *There is risk to a child or vulnerable person *There is a legal requirement to disclose information. Where possible, this will be discussed with you openly and transparently.

Respect and Behaviour in Sessions

The counselling space is built on mutual respect. You agree to: *Treat the therapist and therapy space respectfully *Avoid abusive, threatening, discriminatory or inappropriate behaviour *Engage in sessions in a way that supports emotional safety. Strong emotions are welcome. Harmful behaviour is not.

Boundaries of the Therapeutic Relationship

To maintain safety and professionalism: *Contact outside sessions will follow agreed professional boundaries *The counselling relationship is not social or personal *Therapy is limited to scheduled session times This supports clarity, safety, and healthy independence.

Feels and Payment

This service operates on a fair-access slide scale model to balance sustainability and accessibility. Please select the option that best reflects your circumstances:
Choose Your Session Fee(Required)
Where flexibility is needed, an alternative fee may be agreed. This structure reflects the professional responsibility, emotional labour, and safeguarding complexity involved in this work.

Payment Expectations

Payment is due at or before each session unless otherwise agreed. Please inform your therapist in advance of session if your financial circumstances change. Fees may be reviewed periodically by mutual agreement. Open communication supports transparency and sustainability.

Additional Professional Time (Meetings/Reports)

The session fee covers the counselling time only. Attendance at external meetings (such as case conferences, multi-agency meetings and reviews) and the preparation of written reports, summaries or professional correspondence are not included in the session price, and are charged at £65 per hour in 15-minute increments. This will be discussed and agreed in advance wherever possible. Where additional professional input is requested or required: *This will be discussed in advance wherever possible. *time will be charged separately at an agreed rate *Consent will be sought before information is shared This ensures transparency, fairness, and appropriate recognition of the additional time and responsibility involved.

Cancellation and Attendance Policy

A minimum of 24 hours notice is required to cancel or reschedule appointments. *Cancellations with less that 24 hours, notice or missed appointments may be charged at the agreed session rate. *Exceptions may be considered in genuine emergencies. *Please communicate as early as possible if you are struggling to attend This policy protects the therapist time and allows appointments to be offered to others.

Information Sharing & Support Network Consent

Purpose of Information Sharing

You may choose to allow your therapist to share relevant information with selected professionals or trusted individuals involved in your care. This may support: *Joined-up care *Emotional and practical support *Risk management and safeguarding *Coordination of services You remain in control of this choice.
What Information May be Shared (Tick All That Apply)(Required)
Online relevant information will be shared on a need-to-know basis

Who You Give Permission To Share Information With

Person/ Service 1(Required)
Person/Service 2

How Information Will Be Shared

Information will be shared: *Respectfully and professionally *With your awareness where possible *In line with safeguarding responsibilities *Only when relevant and appropriate

Safeguarding Note

There may be circumstances where information must be shared without consent if there is: *Serious risk of harm to you or others *Risk to a child or vulnerable person *A legal requirement to disclose information This is done to protect safety and wellbeing.

Duration of Consent

Please select one:(Required)
MM slash DD slash YYYY
Client Name
MM slash DD slash YYYY

Privacy Preference Center