Initial Application Form

You must be a resident of Kent or the London Borough of Bexley to access the available services.
Please complete all sections of this form.
Should any information not be completed your form will be returned to you and this will delay your application being processed.
Please note, if you are currently receiving therapy elsewhere, we are unable to offer our support at this time, as running concurrent therapy sessions is not suitable for effective progress.

Referral Information

Self Referral Deselect if not a self referral

Applicant Contact Details

Client type

Client First Name

Client Last Name

Date of birth (dd/mm/yyyy)

Address Line 1

Address Line 2

Town

Postcode

Client Tel Number

Alternative Safe Contact Details

Permission to Leave Voicemail

Permission to Send Text

Permission to Contact via Email

Permission to send Post

Client Email

Parent/Guardian Details

If this application is for a client aged 17 or under, please complete the Parent / Guardian Contact Details below.

Contact type

Contact Name

Address Line 1

Address Line 2

Town

Postcode

Address Permissions

Phone type

Phone number

Phone Permissions

Email Address type

Email address

Email Permissions

Client Details

Please complete this section if you are comfortable to, as this information is used for data analysis and funding purposes, helping us to continue supporting the community.

Sex

Biological Sex registered at birth

Gender

Gender identity

Sexuality

Client Ethnicity 1

Client Ethnicity 2

Nationality

Immigration Status

Primary Language

Interpreter Required

Marital Status

Religion

Employment Status

Accommodation

Living With

Dependants

Have you/are you aware if client has previously used our services?

Medical Details

Surgery Name

GP Name

Address

Phone Number

Email Address

Disabilities (please select all that apply)

Please provide any further information in the Further Information box further down the form. (If you have seizures, please write what action should be taken in an emergency and your emergency contact details)

Medications relating to Mental Health (please select all that apply)

Medication details

Harm and Risk

Incident Impact (please select all that apply)

Have you recently contemplated suicide?

Have you recently self harmed in a serious or life threatening manner?

Please note if you have harmed yourself or taken serious risks with your health we will need to write to your GP or Mental Health Professionals as part of our risk assessment.
If you have thoughts of hurting or harming yourself we would urge you to contact your GP to discuss how you are feeling and seek support.
If you feel you need help now please call your GP, 111 out of hours or your mental health crisis team, or go to A&E. If you have seriously harmed yourself call 999 or go straight to A&E.

Do you take drugs that may affect your attendance/ability to function at sessions?

Do you consume more than the recommended alcohol intake per week? (14 units)

To access support with FM you will be required to be free from drugs or alcohol when attending sessions.

Are you pregnant? If so, please provide your estimated due date

Have you been cautioned or convicted of a criminal offence?

Please provide what offence was committed, what the sentence was and when did the offence occur

Mental Health

Please list all that apply ('None' can be selected from the list)

Mental Health Team Details

Are you live with a Mental Health Team at the moment?

Organisation

Contact Name

Address

Phone Number

Email Address

Have You Experienced Abuse

We apologise for the delicate nature of some of these questions, however we need this information to ensure the best pathway for your support

Presenting incident

Incident occurences

Incident Start Date (dd/mm/yyyy)

Incident End Date (dd/mm/yyyy)

Age at Time of Assault

What is the abusers relationship to you/survivor?

Are you dependent on the abuser?

Do you have any contact with the abuser?

If you have selected ‘yes’ to either of these questions, please provide details on how you are dependent on the abuser, or what kind of contact you have with the abuser?

Sexual Health Clinic (SARC) Attended

SARC Attendance Date (dd/mm/yyyy)

Crime Reporting

Reported to police

Date Reported (dd/mm/yyyy)

Crime Ref No

Police Force

Police Force detail

Officer rank

Officer First Name

Officer Last Name

Officer Collar Number

Phone Number

Email Address

Court case pending

Court Start Date (dd/mm/yyyy)

Social Services

If you are open with Social Services, please complete the below. If not, please move onto the next section.

Organisation

Contact Name

Address

Phone Number

Email Address

Social Services Involvement

Please name any other organisations or workers involved – including name and contact details of support workers

Further information or issues relevant to this referral

(Has the survivor/victim been investigated for any sexual/violent offences?)

(If you have seizures, please write what action should be taken in an emergency and your emergency contact details)

Availability

Family Matters is a registered Charity that provides free specialist support for all survivors of rape and sexual violence to residents of Kent and the London Borough of Bexley.
We offer the following support options. Please indicate which service you require. If you are unsure our team will call to discuss our services with you.

Therapy

Service criteria /explanation of services (Click here to show/hide details)

Therapy

Sessions offered via telephone, video call or face to face.*

*Sessions offered via telephone or video call only for London Borough of Bexley residents who are 18 years old or over due to funding restrictions.

(Therapy available to Residents of Kent and London Borough of Bexley)

Do you have a preference for face to face or online sessions?

Available times (please select all that apply)

Face to Face Therapy is available at the following venues. Please select up to 3 that you can travel to, in order of preference (e.g. 1, 2 and 3)

Therapy Venue 1st choice

Therapy Venue 2nd choice

Therapy Venue 3rd choice

As a charity we have limited staff and availability at venues. Appointments are generally available Monday to Friday 9am to 5pm. Later appointments may be available, but should you require this you may be asked to travel to a venue that you have not included in your choices. Therefore, the more availability you have, the easier it will be to setup appointments and reduce your waiting time.

Statement of Confidentiality

Any information you give to Family Matters will be treated as confidential unless you tell us otherwise. In order for us to provide a good service the information that you give to us is confidential to this organisation, not to a particular staff member. We will only collect the information that we need to enable us to offer you a service and to monitor and evaluate that service.

We do not pass any information on to anyone else without your permission except in extreme circumstances, for instance if there was a serious risk of harm to someone e.g. in cases where we have concerns about the well-being of a child or vulnerable young person / adult, or where a third party may be harmed if the information is not disclosed. Anyone can be in a gang, however if your involvement with a gang is linked to illegal activity, trafficking, drug dealing or violent crime we need make you aware that we would have a duty to report this to the police or social service.

To avoid us having to ask you for the same information more than once, it will be necessary for us to keep certain records. This may include written information about your health and care needs of family members or any problems you may choose to share with us. This information will be stored securely and used only for the purpose for which it was supplied. If you are not satisfied, in any way with the service we provide, we have a complaints system and any issue you raise will be taken seriously and attended to. Information relating to these procedures can be obtained by contacting the Family Matters office on 01474 536661.

If you wish to see the records we hold about you, you may do so at any time, provided you give us reasonable notice. You may be asked for some form of identification so that we can verify that you are the person to whom the information relates.

If you require any further information about Family Matters policy on confidentiality or how we comply with the law on Data Protection, please do not hesitate to contact us.

FM Contract Agreement

Therapy is a commitment, which requires trust, honesty and continuity from both client and therapist. This work needs to be held within safe boundaries. The following is a contract to which both the client and FM agree:

Confidentiality

I agree that I can expect total confidentiality with the exception of:

Disclosure of self-harm or intention/act to harm others.
Disclosure of unreported abuse on a vulnerable person or a child under 18 or possible risk of abuse to others.
If a request is made by a Court or a person with parental responsibility, then Family Matters will have to provide records. If the Police request notes, we will seek your consent first.
FM may contact the appropriate medical professionals or other relevant agencies if required.
In cases where legal proceedings are ongoing therapy will follow the CPS pre-trial therapy guidelines, ensuring that sessions are supportive without compromising legal processes. Any request for therapy notes from legal entities will be discussed with you and written consent will be required before disclosure unless mandated by law.

Sessions:

Sessions will last for 50 minutes.
There will be 12 therapy sessions, once a week, unless agreed otherwise.
If you cannot attend an arranged session, you need to inform FM Office – 01474 536661 and give at least 3 days’ notice or the session will be counted.
If you do not inform FM and miss a session, it will count as one of your 12 sessions.

Expectations:

If I have withheld information, then FM reserve the right to end my engagement with the service.
I confirm I am willing to be free from drugs and alcohol whilst attending sessions with FM.
There is no social interaction outside the therapy.
I have read and understood the ‘Statement of Confidentiality’, or it has been read and explained to me.
I agree for Family Matters to store personal information in accordance with the General Data Protection Regulation (GDPR). (Information regarding the GDPR can be found in the Family Matters Privacy Policy as well as at www.ico.org.uk)
I understand that FM is a charity with limited resources and may not always be the most suitable service for me and FM may, in their discretion, refuse or cease support.

Feedback:

It is important to Family Matters that service users are involved in the delivery of our service. We want to give you the opportunity to tell us if you have experienced a problem. To seek improvements in our service your feedback is particularly relevant to us and the care you receive should be of a high standard. Our remit is to help improve your life and we don’t want you disengaging from therapy or support because you have a problem that you cannot share with us. Please call us on 01474 536661 to discuss any problems you might have.

Consent

So that we can work in a multi-disciplinary way and to ensure we offer a treatment plan that your support providers are in agreement with we kindly request further information from them including any relevant medical or mental health conditions and any suicidal or self-harm ideation. Further to this, we request they please advise us of any therapy or other support you have received in the past few years in relation to this issue. If they have their own Risk Assessment document and are able to share it with us this would also be much appreciated.

Please be advised that we may not be able to continue with the application and risk assessment process until we have received this information from all your support providers.

Please note that if required, Family Matters may contact any of the following in order to complete our risk assessment. By signing this application below, you are agreeing that FM may contact these providers, if required.

Early Help
Mental Health Services
Drug & Alcohol Support
GP
Social Services
Education Provider

Any personal information we receive is only used for the purpose of which you have been informed and only to complete your specific request for support. Please see our privacy policy for further information.

By submitting this form you understand that your data is processed in accordance with our privacy notice