Registration

To join our waiting list you need to complete our registration form.

  • In each section indicate the responses which most accurately apply to you

  • Complete as much of the form as you can

  • If you have problems we can help you to fully complete the form at your first appointment

Your information will be held securely and confidentially - please ensure you’ve read our privacy notice.

If you would prefer to complete the form with pen and paper and post it to us, you can download it here or call us on 0114 275 2157 to request that a form be posted out to you.

Name *
Name
Your contact details
Remember to let us know if you change any of your contact details
We need your full address even if you prefer that we don’t write to you
Are you happy for us to write to you? *
Would you prefer us to call or text you? *
Please also tell us if it is ok to leave a message if we call you.
Are you happy for us to contact you by email? *
Is it ok to contact you on your home phone? *
Please also tell us if it is ok to leave a message if we call you.
I am generally available to attend regular weekly appointments on: *
Indicate all that apply. Appointments are generally between 9am and 5pm with the last appointment at around 4.00pm although we do have some evening appointments.
Have you used our service before? *
The name of your surgery or medical centre - and the name of your GP if you see a specific doctor
The contact number of your surgery or medical centre
In each section below indicate the responses which most accurately apply to you
Living situation *
Do you have caring responsibilities
What is you employment status?
Indicate whichever best describes your main occupation
Please note, below, if you are in receipt of any work-related benefits e.g. income support, incapacity benefit or statutory sick pay
Why you want our service *
we are a specialist service for women in Sheffield who have experienced/are experiencing complex trauma and/or abuse. Please indicate, below, the issues you have/are experiencing indicate as many as apply to you.
Have you seen a counsellor/therapist previously - if so, where?
Indicate as many as apply
Have you had care/support for emotional/psychological difficulties from any of the following?
Indicate as many as apply
Are you currently being prescribed medication for emotional or psychological problems?
The following questions help us to make sure that we provide the best service for all our clients and that we don’t discriminate against any section of our community
Gender
Sexual orientation
How would you describe your race/ethnicity?
WHITE
BLACK
ASIAN
MIXED
How would you describe your religion/beliefs?
Do you consider that you are affected by any of the following?
Indicate as many as apply
What is your first/main language?
How well can you speak English?
I understand that Saffron Sheffield is a service for women survivors of abuse and trauma who live in Sheffield *
The personal data collected on this form will be kept secure and confidential within Saffron Sheffield. Your personal data will only be used for the purpose of client support and monitoring within Saffron Sheffield. Please ensure you’ve read our Privacy Notice Saffron Sheffield does share anonymised and unidentifiable information with funders in support of our work. *