Please use this form to make referrals to our mental health services and ensure you have all information to hand as you cannot revisit it later.

PLEASE NOTE: You will need to have signed the relevant Service Level Agreement and/or have been given permission by YMCA Trinity Group’s Mental Health Services to make a referral so your setting name can be added. If this doesn’t appear in the drop-down for that question, please contact us on mentalhealthservices@ymcatrinity.org.uk or 01733 373187 so we can add you.

Date of Referral*

Contact name of referrer (Please enter the name of the person making the referral. If this is a staff referral, please make sure the name of referrer is the client’s manager)*

Email address of referrer (please enter an email address in case we need to contact you. If this is a staff referral, please put the client’s manager email)*

Setting Type*

Setting Name*

Setting Postal District*

Setting County*

Twitter link

Where did you hear about us?

Client Surname*

Client First name*

Client Date of Birth*

Client Age at referral*

Client Gender*

Client Ethnicity*

Programme referred to: (Mandatory completion - please tick the relevant box. Your referral may be rejected and need to be resubmitted if no programme is selected)

1to1 Therapy

Emotional Management Group

Self Esteem & Confidence Group

Social Skills Group

Yr6 Transitions Group

1 to 1 Mentoring

Family Work

1 to 1 Supervision

Group Supervision

1to1 Counselling (Staff)

Yr7 Transitions Group

1to1 Counselling (CYP)

Group Name (Where applicable, if you are making group work or group supervision referrals for multiple groups, please state which group this referral belongs to e.g. group 1, group 2 etc. There are a maximum of 4 referrals per group. If you are making a referral following a reflective supervision skills course, please include the date your course started, followed by ‘RSS’ and the group you have been allocated to).

Emergency Contact Name

Emergency Contact Number

Primary Email Address

Mobile Number

Alternative Number

Reasons For Referral (Please complete for all programmes except Staff 1to1 Supervision or Group Supervision. If referring for these programmes, please just complete the ‘Desired Outcomes’ questions in this section):

Domestic violence

Anxiety/depression

Suicidal thoughts

Poor social skills

Family

Criticism/failure/rules

Self harm

Eating disorders

School/learning

Bereavement

Attachment

Medical issues

Harm to others

Abuse

Learning disability

Self esteem/confidence

Behaviour

Other (specify below)

If Other please specify

Background information and more detailed reasons for referral (including family make-up and environment) :

Please give details of other interventions this child has received:

Please give details of any diagnosis/medication/allergies:

Please give details of any behaviours or triggers we should be aware of:

Please give up to four desired outcomes:Outcome 1

Please give up to four desired outcomes:Outcome 2

Please give up to four desired outcomes:Outcome 3

Please give up to four desired outcomes:Outcome 4

Do you have a signed Parental Privacy Agreement (Yes No)

This is a requirement. Please email the signed agreement to mentalhealthservices@ymcatrinity.org.uk*

Do you have a signed Parental Privacy Agreement (Yes, No, N/A). This is a requirement for all group work and family work regardless of age. For a client referred to 1to1 mentoring or 1to1 counselling a parental privacy agreement is only needed if they are under 13. If the client is over 13 then they will need to sign a privacy agreement with the counsellor at the first session. Where applicable, please email the signed agreement to mentalhealthservices@ymcatrinity.org.uk.*

For all Primary School and SEN Provision Referrals and for all Secondary/FE college group work, family work and 1to1 mentoring. Not required for Secondary or FE college 1to1 counselling - Teacher Strengths & Difficulties Questionnaire. Please complete the following in order to help us assess needs and suitability. The same person should then complete another questionnaire at the end of provision (this will be sent to you)

Date

Perspective

Type

Considerate of other people's feelings

Restless, overactive, cannot stay still for long

Often complains of headaches, stomach-aches or sickness

Shares readily with other children (treats, toys, pencils etc.)

Often has temper tantrums or hot tempers

Rather solitary, tends to play alone

Generally obedient, usually does what adults request

Many worries, often seems worried

Helpful if someone is hurt, upset or feeling ill

Constantly fidgeting or squirming

Has at least one good friend

Often fights with other children or bullies them

Often unhappy, down-hearted or tearful

Generally liked by other children

Easily distracted, concentration wanders

Nervous or clingy in new situations, easily loses confidence

Kind to younger children

Often lies or cheats

Picked on or bullied by other children

Often volunteers to help others (parents, teachers, other children)

Thinks things out before acting

Steals from home, school or elsewhere

Gets on better with adults than with other children

Many fears, easily scared

Sees tasks through to the end, good attention span

Do you have any other comments or concerns?

Overall, do you think that the/your child has difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people?

If you have answered "Yes", please answer the following questions about these difficulties:

How long have these difficulties been present?

Do the difficulties upset or distress the/your child?

(Parents/Carers only) - Do the difficulties interfere with your child's everyday life in the following areas? - Home Life

(Teachers & Parents/Carers) - Do the difficulties interfere with the your child's everyday life in the following areas? -Friendships/Peer Relationships

(Teachers & Parents/Carers) - Do the difficulties interfere with your child's everyday life in the following areas? - Classroom Learning

(Parents/Carers only) - Do the difficulties interfere with your child's everyday life in the following areas? - Leisure Activities

Do the difficulties put a burden on you or the family (Parents/carers perspective)/you or the class (teachers perspective) as a whole?