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Sexual Trauma & Abuse Restorative Therapies

Advice & Support Line
01962 868 688
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Under-18 Referrals (V2.0)
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Referrer Details

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(DD/MM/YYYY)

Young Person's Details

Address
Town/City
County
Postcode
Country
(No spaces)
(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.)
(DD/MM/YYYY)
Ethnicity
Gender
Disability

Parent / Guardian's Details

(Mr, Ms, Mrs, Miss, Mx, Dr, etc.)
Parent / Guardian's Address (if different)
Town/City
County
Postcode
Country
(No spaces)
Are the parents aware of the incident(s)?

Referral Details

Are the police involved?
If there is currently an on-going investigation, this will be a referral for the Frankie Service – https://yellowdoor.org.uk/frankie-service/
Are social services involved?
If yes, please give social worker details and explain involvement
(Details)

Is the Young Person under the care of CAMHS?
Is the Young Person currently receiving any counselling / therapy?
Is this for something that happened within the last 12 months?

Are the school / college aware of the incident(s)?
(No spaces)

Counselling Details


(Google, Winchester Council, Word of Mouth, etc)

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
Please tick to indicate that you have given your consent for START to hold and process your information
Please tick to indicate that the client has given their consent for START to hold and process their information

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