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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. 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, we will keep your referral open for two weeks, after which time should you not have established contact with us we will close the referral. Please note if we are not the right service for you, we will do our best to signpost you.

Our assessments and services are free. However, if you do not attend an assessment at the agreed time and fail to cancel with at least 24 hours notice, any rearranged assessment will be eligible for a charge.

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.

Over 18 Self Referrals (V2.0)
* 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.
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 your 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 - Your 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.
Your gender?
Your sexual orientation?
Your 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?
Your relationship status?
Current Pregnancy and / or Maternity:
Please tick any that currently apply to you.
Your caring responsibilities:
Please tick any that currently apply to you.
Your current accommodation?
Your current employment / work status?
Please tick any that currently apply to you.
Education:
Please tick any that currently apply to you.

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 your referral relate to Sexual Abuse that happened in childhood?
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:
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 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

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

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

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

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