Registration Form

This information helps us understand more about you and whether we are the best service for you at this time. Some of the questions relate to sensitive information.

All information you provide on this registration form is confidential; this means it is kept safe and secure within SRASAC and will not be passed on to anyone or any other organisation, outside of SRASAC.

If you have any questions, or need help to complete this form contact us on our Information and Support Line on 07517 100 757 or call the office on 0114 241 2766.

Personal information

Please make it as easy as possible to support you by providing as many ways to contact you as possible.

Additional details

The following questions support us to make sure we provide the best service for all our users and help us work towards an inclusive service for all members of our community.

Please indicate the issues you are experiencing or have experienced in the past
Please select any incidents you have experienced/are experiencing

Please note that SRASAC does not work with perpetrators or offenders of violence or sexual offences. In the event of a disclosure we will signpost to more appropriate services. See our website for support if this could relate to you.

It is important before you begin your counselling that you understand what happens to the information you tell us. Please read the following and tick the box to let us know you understand how your personal information will be protected. Your privacy, confidentiality and safety are important to us. If we are concerned about your safety or the safety of someone else we may need to inform another agency, such as your GP or the Police, using the information you have given to us. Your contact details and counselling notes are stored on a secure electronic case management system and cannot be accessed by any other agency. Your assessment notes and counselling notes may be requested by other professionals, for example if you are going through the criminal justice system. We will contact you if any request is made for access to your counselling notes. You can also have access to your notes at any time. You can do this by putting your request in writing to us.

Final questions

It is important for you and us to make sure we are the most suitable service for you at this time and that we are able to offer the support you need. In order to do this, the following questions are designed to find out about any current risk issues or needs you may have, including any safeguarding or child protection issues you may like to discuss. This will help us to make sure that we can provide a safe service for you and all our users.

We recognise that our clients have a right to express their feelings, but do not have a right to abuse, threaten, intimidate or attack (physically or verbally) any person whilst on SRASAC premises. This behaviour will not be tolerated and will result in the withdrawal of our service.

Counselling session information: Our last appointment of the day is around 4pm, except on Tuesdays when we have a limited number of later appointments. When you start your counselling, please note that your counselling sessions will take place on the same day and at the same time each week. It is important that you are able to commit to attending regular weekly sessions and are living in Sheffield for the foreseeable future. WE DO NOT OFFER WEEKEND SESSIONS.

We are aware it is not always easy to access our services; sometimes the time is just not right. If you find you are unable to attend your sessions and your counselling comes to an end, please do not hesitate to contact us again in the future if you feel ready to continue.

Re-referral into the service: As we are a very busy service, we ask that clients use the following time limits before accessing a new episode of counselling:

· If you do not get to the stage of accessing counselling support from our service, we ask that you wait for a period of 6 months before referring back into the service.

· Following the completion of short term Wellbeing Sessions, we ask that you wait for a period of 6 months before referring back into the service

· Following completion of counselling, we ask that you wait for a period of 12 months before referring back into the service.