Referral form - Healthy Valleys

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LDAR Project
Complementary Therapy Service
Healthy Valleys, 31 Stuart Terrace, Rigside
Lanark ML11 9NN Telephone 01555 880 666
Contact details: Carol Hamilton Mob. No 07702336327
Email: carol.hamilton2@nhs.net
As part of the Lanarkshire Domestic Abuse Response project (LDAR) Healthy Valleys provide
free complementary therapy sessions to women who are experiencing (or have in the past
experienced) domestic abuse which has impacted on their health.
The LDAR project aims to improve access to specialist practical & emotional support enabling
more women to become survivors of domestic abuse and to move forward in their lives. The
complementary therapies are on offer to women who live in the Lanarkshire area where the
referral agency feels bodywork therapies would help the client in her recovery process and
where one or more of the following symptoms have been experienced for longer than a month:
 Sleep problems
 Physical health problems
 Anxiety / panic
 Low self esteem
 Emotional numbness
 Difficulty with talk therapy
 Difficulty with touch.
Benefits of bodywork therapies can include:
 Improved sleeping
 Reduced physical tension
 Reduced anxiety / depression
 Improvements in physical symptoms (i.e. digestive health, headaches etc.)
 Increase in confidence & overall wellbeing
Clients referred will have a consultation with the therapist on the first meeting and will discuss
an appropriate course of therapy to suit the individual’s needs.
Treatments available are
 Aromatherapy & Aromatherapy Massage
 Indian Head Massage
 Pregnancy Massage
 Shiatsu
If you feel your client meets the criteria and would benefit from this service please complete the
request for assistance form below and return it to carol.hamilton2@nhs.net or if you have any
questions please do not hesitate to contact Carol on 01555 880 666.
Healthy Valleys is a Company Limited by Guarantee
No: 246145 and is a recognised Scottish Charity No: SC034253
LDAR Project
Complementary Therapy Service
Request for Assistance
Please ensure all sections are completed in full
TO BE COMPLETED BY THE REFERRAL AGENCY (please ensure you have read criteria
above)
In my opinion Click here to enter text.
is a suitable candidate for the LDAR project and I
would like to refer them to the complementary therapy service.
Name of Referral Agency Click here to enter text.
Address of Referral Agency _Click here to enter
text._____________________________________________
Signature of Person Referring Click here to enter text.
Date Click here to enter text.
Contact Telephone Number of Referral Agency Click here to enter text.
REASON FOR REFERAL – Please tick appropriate boxes (to qualify client must have
experienced domestic abuse and at least one other box must be ticked)
Client experiencing domestic abuse:
Currently
☐
In past
☐
☐
Physical Health problems
☐
Low self esteem
Emotional Numbness ☐
Difficulty with talk therapy
☐
Difficulty with touch ☐
Sleep Problems
Anxiety / Panic
Comments:
☐
Depression
☐
☐
Click here to enter text.
CLIENT DETAILS
Name
Click here to enter text.
Address
Click here to enter text.
Postcode
Click here to enter
text.
Safe contact details
(i.e. phone no,
email or address)
Date of birth
Click here to enter text.
Space for any other
relevant information
Safe to contact?
Click here to enter a date.
Preferred
location to
attend
Able / willing to
travel within
Lanarkshire?
By Letter ☐
By Phone ☐
By Email ☐
Click here to enter
text.
Yes ☐
No ☐
Click here to enter text.
Data Protection Act 1998
Information will be kept for no longer than necessary and stored in the most appropriate way. We
may also pass on your details to other organisations associated with the project.
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