Fill out one of our online referral forms

Break The Silence provide support for residents in East and North Ayrshire (aged 13+). In addition we can provide support for people who were abused/neglected as children while living in care in Scotland as we are a pan-Ayrshire provider in partnership with Future Pathways.

Break the Silence welcomes people of all genders without prejudice and supports equality and diversity. However we are unable to support people who have a charge, conviction or committed any sexual offence.

We will endeavour to ensure appointments are at a convenient time. However, due to operational demands on our service and outreach premises only accessible on certain days, this may not always be possible.

OK to send mail?* (Envelopes are plain and do not identify sender)
YesNo

OK to leave message?*
YesNo

OK to email?
YesNoN/A

Preferred contact method?* (please select those that apply)

Reason for referral?* (please select those that apply)

I give consent for my data to be held*
YesNo

As a friend/family member of someone who requires support, you can make a referral on their behalf.  However you require to confirm that you have obtained the individual’s consent to submit this referral as without this consent we are unable to accept  this application.

Friend/Family Member Details

OK to send mail?*
YesNo

OK to leave message?*
YesNo

OK to email?
YesNoN/A

Preferred contact method?* (please select those that apply)

Reason for referral?* (please select those that apply)

I have obtained consent from the individual above to submit this referral and for their data to be held*
YesNo

Referrer Details

Client Details

OK to send mail?*
YesNo

OK to leave message?*
YesNo

OK to email?
YesNoN/A

Preferred contact method?* (please select those that apply)

Reason for referral?* (please select those that apply)

Has your client given consent for this referral and for their data to be held?*
YesNo

Referrer Details

We can confirm the Client’s initial appointment to referral agents however, due to the confidential nature of our service please be aware that third parties will not be privy to services/appointments or any other information regarding the Client thereafter unless the Client has signed a confidentiality waiver.

Do you wish a copy of the initial appointment for your Client?*
YesNo