Kinergy Referral Form



About Us
Kinergy is a charity offering support through specialist, trauma-informed counselling and therapeutic groups to people of all genders aged 18 and over. Our services are offered to anyone who lives in Bristol, South Gloucestershire, BANES and North Somerset who have experienced any form of sexual abuse or violence during their life. 

Important Information
  • Please note that if you have had counselling with us in the last 12 months, we will not be able to accept a referral. Please wait 12 months from your last session.
  • If you move out of our service delivery area whilst on the waiting list/during your sessions we will no longer be able to continue to offer our services.
  • Please update us if your contact details change. If we are unable to make contact with you, you will be removed from the waiting list.
  • If you are completing this form on someone else’s behalf, consent must be obtained.
  • If there is missing information we may return the referral.
Please answer the following questions as completely as possible. 
We understand that some of the questions are quite personal and want to assure you that all data provided will be stored within our secure records system which has the highest levels of security. 

At the bottom of this form is a blue button you must click to submit the information.
About the Referrer
About the new client
In format DD/MM/YYYY
Must be a valid email
Select all that apply
About the services requested
We offer 1:1 Counselling and also 3 types of group therapy, as described below. If you are interested in groups please indicate which group. 

You can also select types of Group Therapy, tick relevant box if interested...
Online group (3 weeks) that provides support, wellbeing advice and a chance to connect with others. Small, mixed gender groups. Suitable for anybody on the waiting list for 1:1 counselling and/or other group therapy.
Art and body focused group therapy at Kinergy premises (9 weeks). Small, single gender and/or mixed gender groups. Suitable alongside or after 1-1 counselling.
Creative Group Therapy in Nature based on community land at Grow Wilder, Frenchay BS161EL (12 weeks). Small, single gender and/or mixed gender groups. Suitable without, before or after 1-1 counselling.
Reason for referral to Kinergy
Tick all that apply
Accessing Our Services

Equalities monitoring
Thank you very much for the referral, our team will be in touch shortly.


Once we have received your referral it will be processed within 5 working days and you will receive an email or text confirmation along with an estimate of how long our current waiting time is. When you have reached the top of the waiting list you will be contacted to arrange an assessment.

If you are looking for some support before we are able offer our services, here are some organisations to contact:
  • Contact your local GP or the NHS helpline on 111
  • NHS Mental Health crisis line 0800 953 1919  (open 24 hours a day, every day)
  • Samaritans Bristol 116 123 (Freephone).
  • SARSAS helplines: 0808 801 0456 or 0808 801 0464
  • Womankind helpline number for women: 0117 9166461 or 0345 458 2914

Equality and Diversity
Kinergy actively promotes equality and diversity and is committed to providing a safe environment and fair treatment of all clients and staff.  As such, we do not tolerate any form of discrimination, and reserve the right to terminate your counselling should discriminatory language, attitudes or behaviour be used. If you feel you have been discriminated against please follow our complaints procedure. Kinergy takes all complaints seriously and follows due process.