Is this referral being made by:*

Forename(s) of child or young person*

Surname of child or young person*

Date of birth of child or young person*

Address line 1*

Address line 2*

Town/City*

Postcode*

Main Telephone Number*

Email address*

NHS Number of child or young person*

Ethnicity of child or young person*

Gender of child or young person*

Child or young person’s GP surgery name and address*

School*

Forename(s) of a person with parental responsibility (essential if child or young person is under 16)

Surname of a person with parental responsibility (essential if child or young person is under 16)

Address of person with parental responsibility (if different to address given for child or young person)

Contact number for person with parental responsibility (if different to that given for the child or young person)

Email address for person with parental responsibility (if different to that given for the child or young person)

Please provide details of the reason for this referral – include an overview of current difficulties*

Please provide relevant social history - such as family circumstances, life events, bereavements, domestic abuse, substance misuse etc.)

Please provide any additional information that may be helpful - including services that the child or young person is currently engaged with or has recently engaged with and any known risk factors. If the child or young person attends a school that has a Mental Health Support Team, you must tell us here that you have spoken to your MHST before completing this referral and provide details of your conversation with them. If the child is at a school with an MHST and you do not confirm that you have spoken to them before submitting your referral, Stay Well will be unable to accept your referral.

Is the child or young person currently in care?*

Is the child or young person a care leaver?*

Is the child a young person a young carer?*

Is there a social worker, family support worker or an Early Help Assessment (open or closed)?*

Does the child or young person have a high level of absence from school?*

Does the child or young person have special educational needs and disabilities*

Does the child or young person have a Youth Offending Team Worker?

Does the parent or caregiver of the child or young person have mental health difficulties?

Is the child or young person homeless or in a housing crisis?

Is the child or young person a refugee or asylum seeker?

Please confirm that the child or young person, or their parent or care giver is aware of our privacy policy and that they consent to the specified information being shared with Staffordshire County Council.*