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Sexual Trauma & Abuse Restorative Therapies

Advice & Support Line
01962 868 688
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For us to consider if we can offer the young person you are representing a service, please complete this form as fully as possible. We will contact you to let you know if we progress your referral to the next stage. If we are unable to reach you or you do not respond to our communications, you will have two weeks to get in touch with us before we close your referral. Please note if we are not the right service for you, we will do our best to signpost you.

Please be aware that 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.

Under-18 Referrals (V3.0) Professionals
* 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)
Agency Address:
Agency Address:
Town / City
County
Postcode
(DD/MM/YYYY)

Section 2 - Young Person's Details

We require some information about the young person in question in order to process this referral.
(DD/MM/YYYY)
Have they accessed START services previously?
We require this information so we can locate their previous records.
Is START aware of the issue / incident they would like support with?
We need this information in order to locate their records and ensure you / they are directed to the most appropriate form of support.
What is the Young Person'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 young person's needs 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 - Young Person'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 Young Person by answering the following questions. All answers you chose to provide will be stored securely and anonymised for use in reports. If you later wish to change your answers or you would like to revoke your consent for us to store and use your answers, please get in touch to let us know.
Gender?
Sexual orientation?
Ethnicity?
Do they consider themselves to have a disability?
Please tick to indicate if any of the following apply to them:
Please tick as many as needed.
Do they take any prescribed medication?
Religion or belief?
If you / they do not wish to answer please state: Do not know
Current Pregnancy and / or Maternity:
Their caring responsibilities:
Please tick any that currently apply.
Their current accommodation?
Are they in any form of current employment / work?
Education:
Please tick any that currently apply.

Section 4 - Referral Details

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?
Does this referral relate to Sexual Abuse that happened when they were aged 13 or younger?
Is the Sexual Abuse ongoing?
What is their relationship to the perpetrator of the Sexual Abuse they have experienced?
Are they currently living with the perpetrator of the Sexual Abuse?
We need to know this in order to best assess their safety and needs.
Is there a current ongoing police investigation into the Sexual Abuse they have experienced?
Are you / they considering reporting the Sexual Abuse they have experienced to the police?
Please tick to indicate if they are affected by any of the following:
Please tick any that currently apply.
Do they require an interpreter?
e.g. please state if they can lip-read, even if this means you do not require assistance.
Please can you indicate how much they have been impacted by Anxiety:
Please can you indicate how much they have been impacted by Eating Problems:
Please can you indicate how much they have been impacted by Low Mood:
Please can you indicate how much they have been impacted by Sleep Issues:
Please can you indicate how much they have been impacted by Self-Harm:
Please can you indicate how much they have been impacted by substance misuse - Alcohol:
Please can you indicate how much they have been impacted by substance misuse - Drugs:
Please can you indicate how much they have been impacted by Suicidal thoughts / ideation:
Do they have a mental health condition or have they received a formal diagnosis of a metal health condition?
Please can you indicate how much they have been impacted by their Mental Health condition:
Are they accessing any Mental Health services?
Do we have their consent to discuss this referral with their GP should we need to?
Have they ever committed or have they ever been investigated for committing any sexual offences?
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

Is it safe for us to speak to their parent / carer about this referral?
IF THEY ARE IN IMMEDIATE DANGER, PLEASE CALL 999. (Please include their name, contact details, what their relationship is to said individual and what organisation they work for, if applicable. Unless it is also YOU, then just state that.)
START works within the Data Protection legislation (DPA 1998 and GDPR 2018) and require explicit consent to hold and process 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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