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Sexual Trauma & Abuse Restorative Therapies

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Refer your child to our service – They are aged 10 or below

If you are the parent / carer / legal guardian of a child aged 10 or below who has experienced sexual abuse, please complete this form to refer your child to START (please be aware that by completing this form you are stating you hold legal parental responsibility for the child being referred). This form should take about 30 minuets to complete and has a lot of questions that might understandably be hard for you to answer.

We ask that you complete this from as accurately as possible – if you are unsure how to answer a particular question, please state “Unknown / Unsure”. 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 your child 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 your child, we will do our best to signpost you.

Please be aware that we require consent from the child you wish to refer 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 your provide in a secure location. Further details about our Privacy Policy are available on our parent Community First’s website.

Important Information for Young People and Parents / Carers:

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 Your Child
* 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.
For example, "I am their mother", "I am their foster carer", "I am their adoptive parent".
Do you live at the same address as the child you wish to refer?
What is your full address?

Please indicate the full street address including house / apartment number, town / city and postcode.

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

Section 2 - About the child you are referring

Please ensure you have gained consent from your child to make this referral, otherwise it may lead to unnecessary delays and an unsuccessful referral.
Has your child accessed START services previously?
We require this information so we can locate their records.
Is START aware of the issue / incident that your child requires support with?
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 your 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
Failure to complete this box may lead to unnecessary delays or an unsuccessful referral.

Section 3 - Your 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 your child by answering the following questions. We appreciate that some of these questions are generic and might not be applicable to your child. 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. If you or your child would like to change the answers provided or have said answers completely removed from their records, please contact us.
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 your 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 your child.

Section 4 - Referral details for your 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 your child's relationship to the perpetrator of the Sexual Abuse?
Is your child currently living with the perpetrator of the Sexual Abuse?
Does the perpetrator of the Sexual Abuse have current access to your child?
We require this information in order to assess your child's immediate needs.
Is the perpetrator of the Sexual Abuse likely to have any access to your child in the future?
We require this information in order to assess your child's immediate needs.
Is there a current ongoing police investigation into the Sexual Abuse they have experienced?
Are they / you (we) considering reporting the Sexual Abuse they have experienced to the police?
Has there ever been any police involvement relating to your child / family?
For example, investigations / prosecutions into the Abuse experienced
Have any court order(s) been made?
Please tick to indicate if your child is affected by any of the following:
Please tick any that currently apply to your child.
Does your child require an interpreter?
Please indicate how much your child is being impacted by Anxiety:
Please indicate how much your child is being impacted by Eating Problems (e.g. suspected or diagnosed eating disorders):
Please indicate how much your child is being impacted by Low Mood:
Please indicate how much your child is being impacted by Mental Health Difficulties:
Please indicate how much your child is being impacted by Sleep Issues / Nightmares / Night Terrors:
Please indicate how much your child is being impacted by Self Harm:
Please indicate how much your child is being impacted by substance misuse - Alcohol:
Please indicate how much your child is being impacted by substance misuse - Drugs:
Please indicate how much your child is being impacted by suicidal thoughts/expressions:
Please tick to confirm if any of the following are relevant for your child:
Please tick any that currently apply to your child.
For example, if your child is experiencing health issues (including allergies), could you please provide further details about them in this box.
Is your child's GP aware of this referral?
Please tick to confirm if any of the following professionals / organisations are CURRENTLY involved with your child / family:
Please tick any that currently apply to your child.
Does your 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 your child / family:
Please tick any that currently apply to your child.
Has any safeguarding been completed for your child?

Section 5 - Strengths and Difficulties Questionnaire

Please give your answers on the basis of your child's behaviour over the last six months. Please answer each item as best you can, even if you are not absolutely certain.
Considerate of the other people's feelings:
Restless, overactive, cannot stay still for long:
Often complains of headaches, stomach aches or sickness:
Shares readily with other children (e.g. treats, toys, pencils, etc.):
Often has temper tantrums or hot tempers:
Rather solitary, tends to play alone:
Generally obedient, usually does what adults request:
Many worries, often seems worried:
Helpful if someone is hurt, upset or feeling ill:
Constantly fidgeting or squirming:
Has at least one good friend:
Often fights with other children or bullies them:
Often unhappy, down-hearted or tearful:
Generally liked by other children:
Easily distracted, concentration wanders:
Nervous or clingy in new situations, easily loses confidence:
Kind to younger children:
Often lies or cheats:
Picked on or bullied by other children:
Often volunteers to help others (parents, teachers, other children):
Thinks things out before acting:
Steals from home, school or elsewhere:
Gets on better with adults than with other children:
Overall, do you think that your child has difficulties in one or more of the following areas: Emotions, Concentration, Behaviour, Being able to get on with other people?
How long have these difficulties been present?
Do the difficulties upset or distress your child?
Do the difficulties interfere with your child's everyday life in terms of - Home Life:
Do the difficulties interfere with your child's everyday life in terms of - Friendships:
Do the difficulties interfere with your child's everyday life in terms of - Classroom Learning:
Do the difficulties interfere with your child's everyday life in terms of - Leisure Activities:
Do the difficulties put a burden on you or the family as a whole?

Section 6 - GDPR and Consent

Do you consent to us contacting the professionals / organisations who are, or have been, involved with your child / 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 your 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 your child's continued safety. This means we may need to speak to other professionals or organisations (e.g. the Police, Children's Services) about your child and the details you have provided within this referral without your explicit consent or before we are able to gain your consent to do so.
Has your child give 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 my 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:

Call our Advice & Support Line on 01962 868 688

Anonymous SMS Text helpline service: 07786 207492

Available 24 hours
(any messages left are checked Mondays-Fridays between 9am-4pm)

Testimonials

"I am now in control of my thoughts and my life. I have gained self-confidence in so many ways and I am no longer haunted by the past."

"I have been given the tools to cope with everyday life. Without counselling I would have continued to deny my situation and feelings which was having extreme detrimental effect on myself, family and friends… RASAC has saved me from self destruction without the support I would have crumbled – a true life saver."

"My RASAC counselling has completely changed my life… I am a better mother, a more involved member of the community and I am able to keep myself safe."

"I was counselled for almost a year. I had a wonderful counsellor who helped me through a very difficult and unpleasant time in my life. It has been a process of healing by revisiting past places which at one time felt unimaginable. The journey has been raw and unnerving but slowly I came to see how I was repairing my damaged self. I finally accepted ownership of what had happened to me and was able to let go of my guilt and shame. My counsellor understood my outlook on life and created a connection with me that was very special. I eventually looked forward to my session as a weekly debrief rather than a purge. I am as happy and confident as I have ever been and I tell people about what I have learnt to help turn their negativity into positivity. Fear can be a very powerful emotion and prevent us from moving on in our lives but once it is confronted the clouds separate and you can focus on that hint of sunshine."

"Thank-you for the support, for the first time since talking about the sexual abuse to someone it is really helping me."

"Thank you so much for all your time and support while I was working through all of the stuff that happened - I really couldn't have done it without your help and input." Male client - June 2021

"The support, understanding and guidance that I've received from START has been life-changing. The whole process has been crucial for me to understand some of the trauma I'd experienced during my childhood. Who I've become as a consequence, who I am today, and how I process some of my thoughts, feelings and emotions." - April 2023

"I cannot thank Sarah at START enough for the counselling I received. I was a bit sceptical of the EMDR therapy I was offered at first but it really has helped me a great deal and I'm grateful for having the opportunity to go through it." - April 2023

"I'd like to thank everyone involved at START. You're doing a phenomenal job. I can't stress how important this journey has been for me. It's been a life altering experience." - April 2023

"Thank you for the Lotus week end, my life is taking a turn for the better and my new journey begins now." - July 2023

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