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Sexual Trauma & Abuse Restorative Therapies

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If you are working with or supporting a child aged 10 or below 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 state “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 valid means of contacting you. We will work to ensure the child 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 we will close the referral. Please note if we are not the right service for the child you wish to refer, we will do our best to signpost you.

Please be aware that we require consent from the child being referred and we will need you to confirm that you have gained that consent before we can process this referral. You will also need to confirm that you have gained the explicit consent of the child’s parent / care giver (the person who holds legal parental responsibility for the child) for you to make this referral. If there is a good reason for you to have not gained the explicit consent of the child and the child’s parent / care giver, you will be asked to explain why in order for us to assess the child’s immediate needs. If you believe the child to be in immediate danger, please dial 999.

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.

Important Information for Professionals / Family Friends:

START has a legal safeguarding duty to protect children and young people. If information is shared with us that indicates sexual abuse has occurred and this has not yet been reported to the relevant professionals or organisations (e.g. the Police, Children’s Services), we are required to notify them ourselves. We will always aim to talk to you first and explain what is happening. Our goal is to work alongside you, not against you. However, protecting the safety and wellbeing of children and young people must come first.

10-and-under - Refer a child to our service
* These fields are required.

Section 1 - About You

We require some information about you in order to process this referral. We will be unable to process the referral if you do not provide your details and a valid means of contacting you.
(No spaces)
Please define your connection to / relationship with the child you are referring:
Address of your organisation:
Address of your organisation:
Town / City
County
Postcode
What is your address?
What is your address?
Town / City
County
Postcode
Are / were you providing ongoing support for the child you are referring?

Section 2 - About the child you are referring

Please ensure you have gained consent to make this referral from the child and the child's parent / care giver (the person who holds legal parental responsibility for the child), otherwise it may lead to unnecessary delays and an unsuccessful referral.
Has the child accessed START services previously?
We require this information so we can locate their records.
Is START aware of the issue / incident that the child requires support with?
What is the child's 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 child 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
(No spaces)
Please tick to indicate if it is safe to:
Please indicate what their relationship is to the child you wish to refer:
Do they share the same address as the child?
What is their full address?
What is their full address?
Town / City
County
Postcode
Is it safe to contact this person by post?
Does this person possess an email address that can be given to us for use to reach the child?
Failure to complete this box may lead to unnecessary delays or an unsuccessful referral.

Section 3 - The Child's 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 child 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 anonymized for use in reports. Please advise the child you are referring to contact us if they wish to change the answers provided or have them completely removed from their records.
What is their gender?
What is their ethnicity?
Do they have a disability?
Please tick to indicate if they have any of the following:
Please tick any that currently apply to the child.
Do they take any prescribed medication?
What is their religion or belief system?
What is their current accommodation situation?
What is their Education situation?
Please tick any that currently apply to the child.

Section 4 - Referral details for the Child

Does this referral relate to an experience of Sexual Abuse?
Does this referral relate to a recent (within the last 12 months) or a non-recent experience of Sexual Abuse?
Is the Sexual Abuse ongoing?
What is the child's relationship to the perpetrator of the Sexual Abuse?
Is the child currently living with the perpetrator of the Sexual Abuse?
Does the perpetrator of the Sexual Abuse have current access to the child?
We require this information in order to assess the child's immediate needs.
Is the perpetrator of the Sexual Abuse likely to have any access to the child in the future?
We require this information in order to assess the child's immediate needs.
Is there a current ongoing police investigation into the Sexual Abuse they have experienced?
Would they like support in relation to this ongoing police investigation?
Are they considering reporting the Sexual Abuse they have experienced to the police?
Has there ever been any police involvement relating to the child you wish to refer?
For example, investigations / prosecutions into the Abuse experienced
Have any court order(s) been made?
Please tick to indicate if the child is affected by any of the following:
Please tick any that currently apply to the child.
Does the child being referred require an interpreter?
Please indicate how much the child is being impacted by Anxiety:
Please indicate how much the child is being impacted by Eating Problems (e.g. suspected or diagnosed eating disorders):
Please indicate how much the child is being impacted by Low Mood:
Please indicate how much the child is being impacted by Mental Health Difficulties:
Please indicate how much the child is being impacted by Sleep Issues / Nightmares / Night Terrors:
Please indicate how much the child is being impacted by Self Harm:
Please indicate how much the child is being impacted by substance misuse - Alcohol:
Please indicate how much the child is being impacted by substance misuse - Drugs:
Please indicate how much the child is being impacted by suicidal thoughts/expressions:
Please tick to confirm if any of the following are relevant for the child:
Please tick any that currently apply to the child.
For example, if the child is experiencing health issues (including allergies), could you please provide further details about them in this box:
Is the child's GP aware of this referral?
Please tick to confirm if any of the following professionals / organisations are CURRENTLY involved with the child / the family of the child you wish to refer:
Please tick any that currently apply to the child.
Does the child have an Education, Health & Care Plan (EHCP) or Education Support Plan (ESP) for adopted children (and similar situations)?
Please tick to confirm if any of the following professionals / organisations were PREVIOUSLY involved with the child / the family of the child you wish to refer:
Please tick any that currently apply to the child.
Has any safeguarding been completed for the child?

Section 5 - GDPR and Consent

Do you consent to us contacting the professionals / organisations who are, or have been, involved with the child / their family to discuss this referral?
At START, we follow a strict confidentiality policy - any information you share with us will not be shared with others outside of START unless you give us your explicit consent. The one exception to this is safeguarding: should we have sufficient reason to believe that the child may be at risk of harm upon reviewing this referral, we are legally obligated to act on any information provided to us in order to reduce that risk and ensure the child's continued safety. This means we may need to speak to other professionals or organisations (e.g. the Police, Children's Services) about the child and the details you have provided within this referral without your / their explicit consent or before we are able to gain your consent to do so.
Has the child and the child's parent / care giver given their explicit consent for you to make this referral on their behalf?
Failure to complete this box may lead to unnecessary delays or an unsuccessful referral.
By selecting "Yes", I am confirming that I consent for START to hold and process the child's information:
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:

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