Rotherham Abuse Counselling Service

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

Your details and requirements

Have you accessed the service before?
Indicate which methods we can use to contact you
Is an interpreter required?
Indicate when you are available for an assessment?
Do you require a downstairs room?
Which is your Preferred counsellor

Diversity information

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.

Which of the following benefits are you currently able to claim
Are you affected by a disability

Details of abuse

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.

Can you confirm that you have experienced abuse?

Please tick if you have experienced any of these issues

Recent (in the last 12 months)
Historical (more than 12 months)
Childhood (under the age of 18)

Confidentiality and Data Protection

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

External Agencies Only

If you are referring yourself, you do not need to complete this section

Does the client know they are being referred for counselling?
Will anyone be bringing the client to the service?
Has the client given you explicit consent to share their details with us?