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Refer Myself

Break The Silence provide support for residents in East and North Ayrshire affected by childhood sexual trauma.

Please fill out the referral form below and we will be in touch as soon as possible.

(Envelopes are plain and do not identify sender)
We are required to collect ethnic origin and gender data for funder reporting purposes. All data reported is anonymised.

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

    At Break the Silence, we only collect the information you choose to share with us. This helps us contact you about your appointments or with other information you have asked for.

    Having a note of some basic details like date of birth, gender, reason for referral, and health information helps us meet our funding requirements. Anonymised data may be used for funder reports, always with care for your privacy and confidentiality.

    By submitting this referral you are agreeing to your data being held as per our Privacy Policy. Under the UK General Data Protection Regulation (UK GDPR), the lawful basis we rely on for processing this information is Legitimate Interest.

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