Fill out one of our online referral forms

Break The Silence provide support for residents in East and North Ayrshire (aged 13+) affected by sexual trauma. In addition we can provide support for people who were abused/neglected as children while living in care in Scotland in partnership with Future Pathways. If you are a South Ayrshire resident, then you may be able to access support through Moving On.

Break the Silence welcomes people of all genders without prejudice and supports equality and diversity. However we are unable to support people who have committed, been charged or convicted of a 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.

Break The Silence collects information from you. We will use this information to contact you with appointment information and to contact you with information of any groups you have expressed interest in. We also collect your date of birth, gender, reason for referral and health statistics to fulfill our contractual/funding commitments. Anonymised data is collated to produce funder/contract reports.

    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)

    Are you a Disabled person?*
    YesNo

    Please tell us which of the following impairment groups apply to you. You may tick more than one box

    We are required to collect ethnic origin and gender data for funder reporting purposes. All data reported is anonymised.

    Ethnicity:
    White ScottishWhite BritishOther BritishAsianMixed RaceBlackIrishWhite OtherWhite EuropeanPrefer not to say

    Gender:

    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)

      Are they a Disabled person?*
      YesNo

      Please tell us which of the following impairment groups apply to them. You may tick more than one box

      We are required to collect ethnic origin and gender data for funder reporting purposes. All data reported is anonymised.

      Ethnicity*:
      White ScottishWhite BritishOther BritishAsianMixed RaceBlackIrishWhite OtherWhite EuropeanPrefer not to sayNot Known

      Gender*:

      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)

        Any current or recent suicidal ideation or behaviours?*
        YesNo

        Are they a Disabled person?*
        YesNo

        Please tell us which of the following impairment groups apply to them. You may tick more than one box

        We are required to collect ethnic origin and gender data for funder reporting purposes. All data reported is anonymised.

        Ethnicity:
        White ScottishWhite BritishOther BritishAsianMixed RaceBlackIrishWhite OtherWhite EuropeanPrefer not to sayNot Known

        Gender:

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

        Referrer Details

        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 unless the Client has signed a confidentiality waiver.