Healing from trauma

The Steps to Healing Programme

Application Form

(To be completed and returned in advance of programme start date)

PARTICIPANT
Name: ______
Address: ______
______/ Postcode:______
Telephone No: ______/ Mobile No: ______
Email:______/ Date of birth: ______

Please give the start date and venue of the programme you would like to attend: ______

Please provide contact details for somebody we can contact in case of an emergency:

Name: ______

Relationship to you: ______

Phone number: ______

How did you hear about The Wider Circle Steps to Healing Programme? ______

______

YOUR BACKGROUND
Have you been affected by the Northern Ireland troubles?
(you do not need to describe how)

Yes No
When did the experience which has impacted upon you occur? : ______
Please describe the support structures you have e.g. friends, family
______
MEDICAL HISTORY
Do you have any medical condition of which TWC should be aware? : Yes No
If ‘yes’ please provide details :
______
Are you currently taking any form of medication? : Yes No
If ‘yes’ please provide details :
______
Are you currently receiving any form of support or counselling related to your trauma? : Yes No
If ‘yes’ please provide details :
______
Please list if you are taking any prescription or non prescription substances which may interfere with your ability to fully engage in the programme? (this may include high volumes of alcohol):
______
EXPECTATIONS
Please outline your reasons for wishing to take part in The Wider Circle Steps to Healing Programme :
______
What do you hope to achieve from the programme? :
______
KNOWN OBSTACLES TO ENGAGEMENT
Are you aware of any other individual involved with the programme who you feel might hinder your ability to fully engage with the programme? :
______
______
Are you aware of any other possible reasons why your engagement with the programme might be hindered? :
______
Please use this space for any additional relevant information you feel is relevant which has not been provided elsewhere: ______
Please complete and return to The Wider Circle, BCDA Building, 283 Ormeau Road, Belfast BT7 3GG or by email to