Referral

Has this referral been consented to?*

Please complete the next section with the referee details.
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Please complete the next section with the child or young persons details.
Surname*
First name*
Date of Birth*
Contact Number*
House Number/Name and Street*
Town*
County*
Postcode*
GP Surgery*
NHS Number
Email*
Do you have a disability?
What type of disability?
Is there any neurodiversity? Diagnosed or suspected
Yes
No
What type of neurodiversity?
Which school
Is school attendance an issue?
Ethnicity
Main Language Spoken*
Emergency telephone number*
Emergency Contact Name*
We require the name and telephone number of an emergency contact before we can accept your referral. This is essential for safeguarding purposes. By submitting this form, you consent to us contacting your emergency contact if we believe you are at risk of harm to yourself or others, or if there are safeguarding concerns.
If you do not have a nominee please contact us on our main referral line number 0808 196 1773.
Reason for referral and are receiving support from anybody else?
Please tell us a brief background of your current difficulties, the duration and impact it is having on functioning. *
Keeping Safe and Well
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Please outline any safety or wellbeing concerns, including:
• thoughts of harming themselves or suicide
• self harm behaviours
• concerns about harm from other people
• concerns about harm to others
Provide as much detail as possible, including any recent changes, triggers, or support currently in place.
If there are no concerns, please write “N/A”.*
Is the child/young person “looked after” as defined in the Children’s Act 1989?
Yes
No
Is the Child/Young Person Adopted?
Yes
No
Are there any safeguarding concerns about the child/young person or family?
Does the child/young person have a child in need (CIN) plan?
Yes
No
Is the child/young person subject to a Child Protection Plan?
Yes
No
Are you or your child currently open to, or receiving, support from any of the services listed below?
Child/YP is "looked after"
Child in need plan
Child protection Plan
Do you currently have a social worker?
Yes
No
Please provide any details of any social workers or professionals supporting you?
Are there any issues that place you or others at risk?
Yes
No
Can this person be worked with on a one-to-one basis?
Yes
No
Is this a referral for a suspected eating disorder?
Yes
No
Please provide details of the issue
Is the person currently restricting their food or fluid intake?
Yes
No
Please list any significant medical history, past and present.
Please list any regular medications that you use.
Wellbeing Questionniare
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Before joining our service, we ask each person to complete a short wellbeing questionnaire. This helps us understand your needs and track your wellbeing over time.
If you are unable to complete this now our staff can support you at a later date, the following questions are not mandatory.
Date
Q1. I've been feeling optimistic about the future
1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time
No answer
Q2. I've been feeling useful
1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time
No answer
Q3. I've been feeling relaxed
1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time
No answer
Q4. I've been dealing with problems well
1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time
No answer
Q5. I've been thinking clearly
1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time
No answer
Q6. I've been feeling close to other people
1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time
No answer
Q7. I've been able to make up my own mind about things
1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time
No answer
Please enter your family member or carer information on the next section
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Main Carers full name*
Parent/Carer DOB
Parent/Carer Contact number*
Address if different from childs
Address line 1
Address line 4 (Town)
Address line 5 (County)
Postcode
Preferred Method of Communication*
Any Disabilities?*
Ethnic Group
Main Disability
Main Language
Referrer details- Please input your details as the main referrer.
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Referrer name*
Work address
Address line 1
Address line 4 (Town)
Address line 5 (County)
Postcode
Telephone number*
Email address*
Job Title
Job Role Category