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Sexual Trauma & Abuse Restorative Therapies

Advice & Support Line
01962 868 688
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If you are caring for, working with or supporting someone aged 18 or above who has experienced sexual abuse, please complete this referral form.

We ask that you complete this form as accurately as possible – if you are unsure how to answer a particular question, please select “Unknown”. We will then contact you to let you know if we can progress the referral to the next stage – we will be unable to process this referral if you do not provide us with your details and a valid means of contacting you. We will work to ensure the person you wish to refer is directed to the most appropriate support. If we are unable to establish contact, we will keep the referral open for two weeks, after which time should you not have established contact with us via some other means we will close the referral. Please note if we are not the right service for the person you wish to refer, we will do our best to signpost you.

Our assessments and services are free. However, if the client does not attend an assessment at the agreed time and fail to cancel with at least 24 hours notice, any rearranged assessment will be eligible for a charge.

Please be aware that we require consent from the person being referred and we will need you to confirm that you have gained that consent before we can process this referral. As part of our referral process, we are required to store any data you provide us in a secure location. Further details about our Privacy Policy are available on our parent Community First’s website.

Professional Referrals (V2.0)
* These fields are required.

Section 1 - About You

We require some information about you in order to process this referral. The referral will not be processed if you do not provide your details and valid means of contacting you.
(No spaces)
Please define your connection to / relationship with the person you are referring:
Are you providing ongoing support for the person you are referring?

Section 2 - About the person you are referring

We are unable to accept referrals without the consent of the person being referred; please ensure you have gained their consent before proceeding otherwise it may lead to unnecessary delays and an unsuccessful referral.
(DD/MM/YYYY)
(DD/MM/YYYY)
Has the person you are referring accessed START services previously?
We require this information so we can locate their records.
What is their address? 

START is a Hampshire-based organisation and offers a number of services across the county. However, not all services we offer are available in all areas of Hampshire. In order to ascertain the needs of the person you are referring and where in Hampshire they are located, we need to know their geographical location. Further details about the catchment area for the services we provide can be found at: https://start-org.uk/contact/areas-we-cover

Address
Address
Town / City
County
Postcode
Is it safe to contact them by post?
(No spaces)
Please tick to indicate if it is safe to:
Is it safe to email them?
(Once you answer this you will be asked for their email address, this is only required if you click yes it is safe to email.)

Section 3 - Their Protected Characteristics

In order for us to provide the best service possible as well as report to our funders about the impact our work is having within the communities we serve, we would be grateful if you could tell us a bit more about the person you are referring by answering the following questions. If you are unsure how to answer a particular question, we ask that you please select "Unknown". All answers will be stored securely and anonymised for use in any reports. Please advise the person you are referring to contact us if they wish to change the answers provided or have said answers completely removed from their records.
What is their gender?
What is their sexual orientation?
What is their ethnicity?
Do they consider themselves to have a disability?
Please tick to indicate if they have any of the following:
Please tick any that currently apply to the person you are referring
Do they take any prescribed medication?
What is their religion or belief system?
What is their relationship status?
Current Pregnancy and / or Maternity:
Please tick any that currently apply to the person you are referring
What are their caring responsibilities?
Please tick any that currently apply to the person you are referring
What is their current accommodation situation?
What is their current employment / work status?
Please tick any that currently apply to the person you are referring
What is their Education situation?
Please tick any that currently apply to the person you are referring

Section 4 - Referral details for the person you are referring

Does this referral relate to a recent (within the last 12 months) or a non-recent experience of Sexual Abuse?
Does this referral relate to Sexual Abuse that happened in childhood?
Is the Sexual Abuse ongoing?
What is the person's relationship to the perpetrator of the Sexual Abuse?
Is the person you wish to refer currently living with the perpetrator of the Sexual Abuse?
We require this information in order to assess the safety and needs of the person you wish to refer
Is there a current ongoing police investigation into the Sexual Abuse they have experienced?
Are they considering reporting the Sexual Abuse they have experienced to the police?
Please tick to indicate if the person you wish to refer is affected by any of the following:
Does the person being referred require an interpreter?
Please indicate how much this person is being impacted by Low Mood:
Please indicate how much this person is being impacted by Sleep Issues:
Please indicate how much this person is being impacted by Self-Harm:
Please indicate how much this person is being impacted by substance misuse - Alcohol:
Please indicate how much this person is being impacted by substance misuse - Drugs:
Please indicate how much this person is being impacted by Suicidal thoughts / ideation:
Does the person you wish to refer have a mental health condition?
Please indicate how much this person is being impacted by their Mental Health condition:
Are they accessing any Mental Health services?
Do we have the consent of the person being referred to discuss this referral with your GP should we need to?
Does this person you wish to refer have any current involvement with the police as a suspect?
Have there been or are there currently any criminal investigations relating to this person offending in anyway?
Has the person you wish to refer ever committed or been investigated for committing any sexual offences?
(Name)
(No spaces)
Please indicate which day and time when they would like their needs assessment to be undertaken:
Assessments take approximately 30 minutes.
Counsellor Gender Preference

Section 5 - GDPR and Consent

START works within the Data Protection legislation (DPA 1998 and GDPR 2018) and require your explicit consent to hold and process your personal information.

For full policy please see: https://start-org.uk/wp-content/uploads/2021/03/Data-Protection-Policy-v2.pdf

Has the person being referred given their explicit consent for you to make this referral on their behalf?
We are unable to accept referrals without the consent of the person being referred; please ensure you have gained their consent before proceeding otherwise it may lead to unnecessary delays and an unsuccessful referral.
By selecting "Yes", I am confirming that I have completed this form to the best of my ability, and that all answers I am about to submit are accurate and factual:

Call our Advice & Support Line on 01962 868 688


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