This form can be used for self-referral or referral by an agency.
Please complete all sections. If you require any assistance please contact us on 01709 835482 or email
Please be aware that we are unable to add you to the waiting list until we have received this form
Rotherham Abuse Counselling Service and all our staff are non-judgemental and non-prejudice. The following information helps us to understand if we are providing a fair and accessible service to all people in the community. You are not required to answer, but it does help us if you answer as much as you can.
We provide support for people who have suffered any kind of abuse at any time in their lives including sexual, domestic, honour based, and childhood.
Rotherham Abuse Counselling Service provides a confidential service. There are occasions where it will benefit your care/support if we are able to contact other agencies working on your behalf.
I give consent for Rotherham Abuse Counselling services to contact and share information with my GP and other relevant agencies involved in my care and those that might do so in the future.
I also agree that Rotherham Abuse Counselling Service can share my details with funders for the purposes of monitoring requirements and to support future funding applications.
I understand that my information will not be passed onto any other third party and that I have the right to request the removal of consent at any time.
Our data protection and confidentiality policies are available on our website www.rothacs.org.uk
If you are referring yourself, you do not need to complete this section