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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 you 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) Self
* These fields are required.

Section 1 - Your Details

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.
(DD/MM/YYYY)
(DD/MM/YYYY)
Have you accessed START services previously?
We require this information so we can locate your previous records.
Is START aware of the issue / incident you would like support with?
We need this information in order to locate your records and ensure you 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 your needs and where in Hampshire they are located, we need to know your 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 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 - 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 yourself 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 you consider yourself to have a disability?
Please tick to indicate if any of the following apply to you:
Please tick as many as needed.
Do you take any prescribed medication?
Your religion or belief?
If you do not wish to answer please state: Prefer not to answer
If you do not wish to answer please state: Prefer not to answer
Your caring responsibilities:
Please tick any that currently apply.
Your current accommodation?
Your current employment / work status?
Please tick any that currently apply.
Education:
Please tick any that currently apply.

Section 3 - Referral Details

Does your 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 you were aged 13 or younger?
Is the Sexual Abuse ongoing?
What is your relationship to the perpetrator of the Sexual Abuse you have experienced?
Are you currently living with the perpetrator of the Sexual Abuse?
We need to know this in order to best assess your safety and needs.
Is there a current ongoing police investigation into the Sexual Abuse you have experienced?
Are you considering reporting the Sexual Abuse you have experienced to the police?
Please tick to indicate if you are affected by any of the following:
Please tick any that currently apply.
Do you require an interpreter?
e.g. please state if you can lip-read, even if this means you do not require assistance
Please can you indicate how much you have been impacted by Anxiety:
Please can you indicate how much you have been impacted by Eating Problems:
Please can you indicate how much you have been impacted by Low Mood:
Please can you indicate how much you have been impacted by Sleep Issues:
Please can you indicate how much you have been impacted by Self-Harm:
Please can you indicate how much you have been impacted by substance misuse - Alcohol:
Please can you indicate how much you have been impacted by substance misuse - Drugs:
Please can you indicate how much you have been impacted by Suicidal thoughts / ideation:
Do you have a mental health condition or have you received a formal diagnosis of a metal health condition?
Please can you indicate how much you have been impacted by your Mental Health condition:
Are you accessing any Mental Health services?
Do we have your consent to discuss this referral with your GP should we need to?
Do you have any current involvement with the Police as a suspect?
Has there been or are there currently any criminal investigations relating to you offending in anyway?
Have you ever committed or have you ever been investigated for committing any sexual offences?
Please indicate which day and time when you would like your needs assessment to be undertaken:
Assessments take approximately 30 minutes.
Counsellor Gender Preference:

Section 4 - GDPR and Consent

Does your parent / carer know you are making this referral to START?
Is it safe for us to speak to your parent / carer about this referral?
IF YOU ARE IN IMMEDIATE DANGER, PLEASE CALL 999.
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

By selecting "Yes", I am confirming that I consent for START to hold and process my 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

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

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