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Sexual Trauma & Abuse Restorative Therapies

Advice & Support Line
01962 868 688
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"Professional Referrals ";s
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Client Details

Address
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Postcode
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(Click as many as needed.)
(Please click No if no email address is set, for safety's sake this is a required field)
(DD/MM/YYYY)
Ethnic origin
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Gender
Please indicate diagnosis
Has the client received a service from local mental health services within the last 12 months?
Does this referral relate to sexual abuse that occurred recently (within last 12 months), non-recently (more than 12 months ago) or during childhood? *

Referral Details

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This is usually a friend or family member that could be called in an emergency. Please speak to the office if you have any concerns.
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GP Address
GP Address
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County
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Service Required
If you think the client might need counselling then please select the option above that would best suit them. If you really have no idea what they want then please select 'No preference'.

Referring Agency

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(Google, Winchester Council, Word of Mouth, etc)

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
Please tick to indicate that the client has given their consent for START to hold and process their information

Call our Advice & Support Line on 01962 868 688 or 01962 864 433


Anonymous SMS Text helpline service: 07860 027 793

Available 24 hours

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