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Understanding Child Sexual Abuse
How To Ask For Help

In case of emergency

Donate

Make a Referral

Professionals
Children, Parents and Carers
Get Involved
- Donate
- Events
- Volunteer
- Fundraising
- News
Understanding Child Sexual Abuse
How To Ask For Help

Complete the Full Self Referral Form

Full Self Referral Form

Child details

Child's Name:(Required)

Address:(Required)

Town:(Required)

Postcode:(Required)

Date of birth:(Required)

Gender:(Required)

Ethnicity:(Required)

Preferred Pronouns:(Required)

Nationality:(Required)

Faith:(Required)

Preferred language:(Required)

Interpreter required:(Required)

Literacy support:(Required)

Legal Status(Required)

Outline any disabilities:

Child's Contacts

School/ College:(Required)

Address:(Required)

Town/Postcode:(Required)

Contact name:(Required)

Telephone:(Required)

Name of GP:(Required)

Telephone:(Required)

Address(Required)

Town:(Required)

Postcode:(Required)

Details of parents/carer with whom the child/ young person is living

Names:(Required)

Relationship:(Required)

Telephone:

Mobile:(Required)

Email:(Required)

Name of parent/ guardian:(Required)

( if different from carer with whom child is living)

Do they have parental responsibility?(Required)

(if not who does?)

Address:

(if different from child)

Postcode:(Required)

(if different from child)

Email:(Required)

Details of referrer

( if different from above)

Name:

Address:

Postcode:

Telephone:

Email:

Date of referral:(Required)

Other agencies involved

(please tick)(Required)

CYPS:

Police:

Health:

Mental Health:

Other (please state)

Please give names and contact details:

Details of sexual abuse

To whom was the sexual abuse first reported?(Required)

Who undertook the investigaion?(Required)

(please tick)

CYPS:

Police:

Date of investigation:(Required)

Outcome of the investigation:(Required)

Crime Reference Number:(Required)

What Police force and contact:

Has there been a Child Protection case conference?(Required)

Yes

No

If yes, category:

Outline the exact nature of the abuse?(Required)

E.g. vaginal rape, touching breasts, anal rape, masturbation, made to watch others having sex

Age of child/ young person when abuse started:(Required)

Age of perpetrator at time of abuse:(Required)

Relationship of child to perpetrator:(Required)

Does the parent/ carer belive the child/YP?(Required)

Yes

No

Does the child/ YP or any member of the family have contact with the abuser?(Required)

Yes

No

If yes, please give details:

Symptoms and behaviour

Child/ Young Person's symptoms and behaviours:(Required)

How do you think the service can help the child/ young person and the family?(Required)

Please outline any mental health concerns: (i.e. self-harm, suicidal ideation)(Required)

Is the Child/ Young Person waiting or accessing support for their mental health?(Required)

Yes

No

If you answered yes to the above, please provide details of the service and lead contact if known:

*Please note our criteria states the child or young person must be accessing or on a waiting list for mental health services if they have moderate to severe mental health concerns. Otherwise, the referral may not be accepted.

Details of Family Court proceedings:

(including custody and contact issues, application for Care Orders and dates, if appropriate)

Is the Child/ Young Person willing to attend sessions?(Required)

Yes

No

Has the child/ young person been referred to the service in the past?(Required)

Yes

No

Is the Child/Young Person related or in any way connected to any child/ young person who has been referred to this service?(Required)

Yes

No

If yes, please give details

Consent(Required)

By consenting to this referral, you are consenting to Brave Futures setting up a case file and processing the referral in order to be considered for receiving a service from us. You are also giving consent for us to contact professionals who are, or have been, involved with the young person (for the purpose of sharing information), and you are also agreeing to us undertaking a risk assessment, should this be necessary. You are also consenting to Brave Futures securely storing and holding onto personal information.

By consenting to this referral form you also understand that Brave Futures do not hold case responsibility at any time

Consent Gained from Young Person agreeing to the referral:

Date(Required)

Consent(Required)

Consent from a parent/carer who holds parental responsibility is required for all referrals.

Consent Gained from Parent/ Carer agreeing to the referral:

Date(Required)

Please make sure all the boxes below are checked before submitting the referral to Brave Futures. If you answer no to any of the questions, we may not be able to accept the referral.(Required)

There has been some form of disclosure of sexual abuse by the child or young person and the abuse has been reported to the police and or CYPS.

The child or young person is under the age of eighteen at the time of referral.

The child or young person does not have contact with the abuser, except where this cannot be avoided e.g. school/college etc.

The child or young person lives in an area for which we are funded, currently Suffolk or Norfolk.

The referral form has been signed by the referrer and the child / young person and the parent/carer have provided their consent.

Please also ensure that you have provided information about the nature of the abuse.

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