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Your first name*

Your last name*

Who are you contacting us about?*

Someone I am supporting in a Professional capacity

Enquiring for support for myself

I am a parent/main carer and the person I am enquiring for is aged 15 years or younger

I am a parent/main carer and the person I am enquiring for is aged 16-18 years

An adult who I care for/support/am concerned about in a personal capacity

Other

To help us to know who in our team should contact, please select all that apply *

I have experienced sexual violence/abuse

I have experienced domestic violence/abuse

I have experienced relational trauma

I have not experienced any of the above and I am contacting you for self-pay counselling for myself

I have not experienced any of the above and I am contacting you for support for someone I know personally

I have not experienced any of the above and I am contacting you for support for someone I know in a professional capacity

Other (please provide further details)

Please share any further information that you think is relevant at this point

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Information you share with Trauma Recovery CIC will be processed and stored in accordance with current legislation. Please indicate that you understand this and give permission for Trauma Recovery CIC to process and store your data by ticking that the box below.

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Trauma Recovery CIC is a multidisciplinary trauma service providing a safe and confidential space for people in the community in relation to sexual, domestic and/or relational abuse.

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