Internal Stream – Apply for Karma Nirvana Counselling

Step 1 of 6 – Self Referral or Professional Details

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About this form

Karma Nirvana’s counselling service offers a safe, confidential space for survivors of Honour Based Abuse (HBA) to access trauma-informed therapy. Our aim is to support individuals in processing their experiences, rebuilding emotional well-being, and developing tools to move forward. This form helps us assess whether our service is the right fit for your needs. If referring someone else, you must confirm their consent before submitting.

Are you self-referring yourself for this service?(Required)

Professional Referral

If you are completing this form on behalf of someone else, please provide your details first. You must have the individual’s consent to refer them for counselling.

Do you have the individual's active consent to refer them to this counselling service?(Required)

We are unable to accept any referrals without consent.

I have recieved consent from the individual to refer them to this service

Professional's Name(Required)

First Last

Name of the organisation you work for(Required)

How long have you been supporting this individual?(Required)

Is your organisation a member of Women's Aid Federation?(Required)

This will not affect the client’s application.

Yes

Are any other agencies involved with the support of this individual?(Required)

For example, police, healthcare, social care.

Yes

If yes, please provide more information about the other agencies(Required)

In your professional opinion, why do you think counselling would be beneficial for this individual?(Required)

Professional's Phone Number(Required)

We will use this to contact you about the application for counselling

Professional's Email Address(Required)

We will use this to contact you about the application for counselling

By ticking this box, you are agreeing to the following misuse agreement:

I understand that if my organisation refers three or more individuals who do not meet the service eligibility criteria, it will be barred from submitting further applications for six months. This measure is in place to prevent misuse of the service.

Client's Details

Please provide information so we can get in touch with you about your application.

For professionals filling out this form on behalf of an individual:

Please fill out the rest of this form with the details of the individual you are applying for.

Name(Required)

For the individual receiving counselling

First Last

Email Address(Required)

We will use this to contact you about your application for counselling

Experiences

We ask the following questions to assess whether our counselling service is the right fit for your needs. Please answer the following questions as accurately as possible to help us understand more about your experiences.

For professionals filling out this form on behalf of an individual:

Please fill out the rest of this form with the details of the individual you are applying for.

Are you female?(Required)

The individual receiving counselling must be female to be eligible for this service. We hope to expand our services in the future

Yes, I am female

Are you over 18?(Required)

The individual receiving counselling must be over 18

Yes, I am over 18

What is your preferred language for communication?(Required)

Our counselling service is only offered in English

English

Have you experienced Honour Based Abuse?(Required)

Please select the option that best describes your experience. Honour Based Abuse (HBA) includes various forms of domestic abuse, coercion, and control that are justified under the concept of honour. This may include: physical, sexual, emotional, or economic abuse, Child Marriage or Forced Marriage, Virginity Testing or Female Genital Mutilation (FGM).

I am currently experiencing Honour Based Abuse

I have experienced Honour Based Abuse in the past

I have not experienced Honour Based Abuse

I’m not sure

Please share any details that might help us understand your experience of HBA(Required)

What is your living situation?(Required)

We ask this to ensure that counselling is safe and appropriate for your circumstances.

I currently live with someone who has harmed or controlled me

I do not live with anyone who has harmed or controlled me

I’m not sure

Do you live with family members?(Required)

We ask this to help us understand your experiences.

Yes

Do you have regular contact with family members?(Required)

We ask this to help us understand your experiences.

Yes – More than once a week

Yes – Once a week

Yes – A few times a month

Yes – Once a month

Yes – A few times a year

Please describe your relationship and contact with family members(Required)

For example, regular calls, visits or messaging, as well as how you feel about your relationship with them. We ask this to help us understand your experiences.

Please share any other details that might help us understand your living situation(Required)

Risk Assessment

Your safety is our priority. These questions help us understand whether counselling is safe for you at this time. Please answer the following questions to help us understand more about your situation.

For professionals filling out this form on behalf of an individual:

Please fill out the rest of this form with the details of the individual you are applying for.

Do you feel safe right now?(Required)

Yes

Are you currently in any immediate danger?(Required)

Yes

Is this the right service for you?

If you are in immediate danger, we strongly encourage you to contact emergency services or our national HBA helpline for further support.

Emergency Services: 999

Karma Nirvana UK Helpline: 0800 5999 247

9am–5pm, Monday–Friday

What is your housing and accommodation status?(Required)

Renting From Private Landlord

Homeowner

Refuge

Emergency Accommodation

Temporary Accommodation

Student Accommodation

Foster Placement

Council Tenant

Hospital Inpatient

NASS Accommodation

Supported Accommodation

Homeless

Other

How long have you lived in your current accommodation?(Required)

Less than 1 month

2-6 months

6 months – 1 year

1-3 years

3+ years

Do you have any reason to believe engaging in counselling could increase your risk?(Required)

Yes

Are you currently involved in any legal proceedings?(Required)

This includes but is not limited to: family court processes, immigration or asylum applications.

Yes

Is this the right service for you?

This service is intended to support healing from past trauma, and legal processes can interfere with this. We strongly encourage you to contact our national HBA helpline for further support, as well as referral information for other services who can support with this process.

Karma Nirvana UK Helpline: 0800 5999 247

9am–5pm, Monday–Friday

If yes, please briefly describe the legal proceeding(s)(Required)

Counselling Readiness and Your Needs

Counselling can be a helpful space for reflection, healing, and support. To ensure this service is the right fit for you at this time, please answer the following questions.

For professionals filling out this form on behalf of an individual:

Please fill out the rest of this form with the details of the individual you are applying for.

Do you feel that you need counselling?(Required)

Yes

Do you feel like now is the right time for you to start counselling?(Required)

Yes

Do you feel ready to face past trauma in a way that might be challenging or distressing at times?(Required)

Counselling sessions can be challenging and require discussion of trauma in depth. Your counsellor will support you through the process, however you must be prepared for this.

Yes

Are you able to attend regular counselling sessions?(Required)

Your counsellor will work with your availability and schedule wherever possible during the process.

Yes

Are there any barriers that might make it difficult for you to attend online counselling sessions?(Required)

This may include access to equipment issues, access to email issues, or access to a reliable internet connection.

Yes

If yes, please tell us about any barriers you might face in accessing counselling

We ask this to understand any challenges you may experience and explore ways to support you.

Do you have any diagnosed mental health issues?(Required)

Yes

If yes, please specify the diagnosis

We ask this to understand any challenges you may experience and explore ways to support you.

Are you currently receiving treatment for any mental health issues?(Required)

Yes

Are you currently on any medication relating to your mental health?(Required)

Yes

If yes, please specify the medication

We ask this to understand any challenges you may experience and explore ways to support you.

Consent & Confidentiality

I understand that this service follows strict confidentiality protocols except where there is a risk of serious harm(Required)

I agree.

I consent to the collection and secure storage of my data for service evaluation and support.(Required)

I agree.

I understand that if I am assessed to be at high risk, my safety will be prioritised, and appropriate safeguarding actions may be taken.(Required)

I agree.

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