Referral Form for those impacted by Sexual Abuse in Swindon & Wiltshire

You may receive help from FearFree or one of our partner charities. You can find information about this at the bottom of the form.

If you have recently been assaulted, you can find immediate practical help here The Swindon and Wiltshire Sexual Assault Referral Centre (SARC) - First Light

Children: The Bridge SARC (Sexual Assault Referral Centre) About us – The Bridge (thebridgecanhelp.org.uk)

If you are making this referral on behalf of a child or young person, you should obtain their consent to share their information with FearFree, Barnados and NSPCC.

Support Required

If you are making this referral for a child or young person please obtain their consent where it is possible. Please tick this box to confirm if you have obtained the child or young person’s consent.

By completing this form, I consent for my information to be shared with FearFree, and held on their confidential database.

I understand that the information provided may be shared if there is a significant safeguarding issue. If FearFree are concerned that I may harm myself or another, or if there is a child at risk of ongoing harm FearFree will share the information with the relevant safeguarding agency.

Please complete as many boxes as possible.

Person completing the form (if different to the client)

Referrers name

Contact number

Referring agency

Contact Email Address

About the client

First Name

Last Name

Preferred Name

Gender Preferred pronouns

Address 1

Address 2

Town

Post Code

Date of Birth

Home Telephone

Mobile Telephone

Email Address

Is it safe to leave a message on the mobile telephone

Preferred contact method

Are there any specific safe times to make contact?

Diversity Information

Gender identity

Religion

Ethnicity

Sexual orientation (optional)

Disability

Details of disability / special educational needs

Does the client have any allergies?

Main language spoken at home

Is a translator required?

Contact Details for Child / Young Person Referrals

Details of safe parent / carer with parental responsibility (who is aware of the abuse)

Parent/carer First Name

Parent/carer Last Name

Parent/carer Date of Birth

Parent/carer Address 1

Parent/carer Address 2

Parent/carer Town

Parent/carer Post Code

Is it safe to post information to the above address?

Parent/carer Email Address

Is email a safe method of contact?

Parent/carer Home Telephone

Is it safe to leave a message on the home telephone

Parent/carer Mobile Telephone

Is it safe to leave a message on the mobile telephone

Preferred contact method

Are there any specific safe times to make contact?

Does young person live with named safe parent / carer? (If no, please give details)

Is this referral being made with safe parent / carer consent?

Name and age of other children related to / living with young person

Relationship to child

Education setting for Child / Young People

Name of school / college

Telephone for school / college

Contact details for key school professional linked to young person

Is the young person currently attending school? (If no, please provide details)

GP Details

GP Surgery Details Include telephone number and e-mail address if known

Reason for request for support

Nature of incident

Please give a brief overview, it is not necessary to give details at this stage

Background

When was the abuse disclosed?

What relationship did the perpetrator have to you?

Does the perpetrator still have contact with you? Please give brief details.

Do you have a Social Worker? Please provide name and contact details

If the client is a child, are they a child in care?

Has there been a police investigation? Please give details.

Is there, or has there been, a court case? Please give details.

Please give details and the outline of any plans in place to support or protect the client.

If a child or young person, are they at risk of Child Sexual Exploitation (CSE)?

If a child or young person, are they at risk of Child Criminal Exploitation (CCE)?

Do you display reactive sexual / harmful behaviour towards others or yourself?

Are there any other concerning factors affecting you? i.e. domestic abuse, poverty, substance misuse, young carer, victim of crime. Please give brief details.

Trauma Symptoms

Please provide a brief overview of the trauma symptoms affecting you.

This could include, but is not limited to, anger, sleep, eating, anxiety, self-harm, bullying, school refusal, risky behaviours, going missing, substance misuse.

Please provide a brief summary of anyone providing you with support at this time.

(Eg, friends, family, support networks)

What are you most worried about and what you would like to get out of the support?

Thank you for your referral. The client can expect to hear from FearFree, or one of the partner organisations if a child / young person within the next five working days to confirm receipt of your referral.

If this person’s situation changes or if the support is no longer needed, please inform us on spa@fearfree.org.uk or 01225 775 276

Adults will receive support from;

Fear Free - Sexual Violence - FearFree

FearFree’s Wiltshire & Swindon Sexual Violence Therapeutic Support Programme offers therapeutic support for anyone in Wiltshire and Swindon who has experienced sexual violence.

Children may receive support from;

Fear Free - Sexual Violence - FearFree

FearFree’s Wiltshire & Swindon Sexual Violence Therapeutic Support Programme offers therapeutic support for anyone in Wiltshire and Swindon who has experienced sexual violence, including specialist child & young person support.

Barnardo’s - Barnardo's Swindon & Wiltshire Pheonix Project

The Barnardo’s Swindon & Wiltshire Phoenix Project offers specialist therapeutic recovery support for any young person aged up to 18 living in Swindon and Wiltshire who has experienced Childhood Sexual Abuse (CSA).

NSPCC - Letting the Future In (LTFI) | NSPCC Learning

NSPCC’s ‘Letting The Future In’ project is designed to help children and young people who have experienced sexual abuse to rebuild their lives.

The organisations listed above provide therapeutic recovery support to recover from the impact of Childhood Sexual Abuse.

If support is needed in the aftermath of an assault, please contact;

Adults: The Swindon and Wiltshire Sexual Assault Referral Centre (SARC) - First Light

Children: The Bridge SARC (Sexual Assault Referral Centre) About us – The Bridge (thebridgecanhelp.org.uk)

If the client needs help to ease any anxiety about going to court by explaining and simplifying the complexities of the legal process please contact;

First Light ISVA (Independent Sexual Violence Advisors) - Swindon & Wiltshire Independent Sexual Violence Advisory (ISVA) Service - First Light