Name of the school you/your child attends? Gateway Academy St Edward’s Catholic Primary School St Joseph’s RC Primary School St George’s Catholic School St Gabriel’s CE Primary School Westminster Cathedral RC School Ark Atwood Primary Academy St Mary Magdalene’s CE Primary School Marylebone Boys’ School King Solomon Academy Hampden Gurney CE Primary School Our Lady of Dolours RC Primary School St Mary’s Bryanston Square CE School St Marylebone CE School Churchill Gardens Primary Academy St Matthew’s CE Primary School St Vincent de Paul RC School The Grey Coat Hospital Christ Church Bentinck CE Primary School Essendine Primary School St Saviour’s CE Primary School Barrow Hill Junior School Harris Academy St Vincent’s RC Primary School Westminster City School Pimlico Academy George Eliot Primary School & Robinsfield Infant School Burdett-Coutts & Townshend Foundation CE Primary School Pimlico Primary Free School All Souls’ CE Primary School Soho Parish CE Primary School St Clement Danes C of E Primary St James & St John's CE Young person intervention:
Pick one or more which in your opinion are the most concerning for you
Email * Phone Parent/carer or young person: Name *
Details of the Child/Young Person
Age Religeon Gender School name Year group Mobile number Ethnicity - Asian/Asian British Ethnicity - Mixed/Multiple ethnic groups Ethnicity - Black/Black British
Any other White background Other - specify here Settled accommodation indicator
Special educational need or disability (SEND)
Details of special educational need or disability Does the child/young person have an Education Health and Care Plan (EHCP)?
Has the child/young person had a mental health intervention before (e.g. CAMHS, school counsellor, Educational Psychologist etc.)?
If yes, please give details: Details of the Main Parent/Carer who can be contacted in case of an emergency: First/ last name Relationship if not parent: Contact details: Other parent/carer name and contact details: Who has parental responsibility? Learning/physical disability?
If yes, please give details: Main language of child/ young person: Is an interpreter required? If so specify language Main language of parent/carer: Is an interpreter required? If so specify language: Gp details - First/ last name: Phone Reason for Referral:
Please give a brief summary of the difficulties you (as a young person) or your child is experiencing (including background information, strengths and existing support)
Please identify any hopes or goals for the treatment? Any other relevant information (family, social and educational factors): PARENTAL CONSENT FORM - Do the parents/carer/guardians (who have parental responsibility) consent to this referral to Mind if the young person is under 16 years old?
(If the consent form is not fully completed this could lead to a significant delay as we will need to contact you to proceed any further).
In order to provide this service, Mind in Brent, Wandsworth and Westminster (BWW) will need to process data relating to the child / young person, as well as their parent / carer. Do you consent to this?
(N.B: this person must have legal parental responsibility for the child / young person).
In order to provide a collaborative service for you / the client, BWW Mind may need to share your / the client’s information with other service providers. We will only share your / the client’s data with consent. Consent can be withdrawn at any time. Sharing data within the service and other services will be discussed with you / the client before any action is taken. Please tick the boxes below, where you consent for data to be shared with:
NHS England’s Mental Health Services Data Set
This is a national data set, which collects data on all clients in England receiving emotional wellbeing and mental health services through NHS-funded interventions.
Parent / Carer’s Name: YOUNG PERSON CONSENT FORM - Required if the young person is 13 years old or over If this consent is not completed fully and the young person is 13 or above, the referrer will be contacted which may lead to a delay of referral process. *
Does the young person consent to this referral to Mind?
If the young person is 16 years and over, does the young person consent to this referral being shared with their parents/carer/guardians? * In order to provide this service, Mind in Brent, Wandsworth and Westminster (BWW) will need to process data relating to the child / young person. Does the young person consent to this? In order to provide a collaborative service for you, BWW Mind may need to share your information with other service providers. We will only share your data with consent. Consent can be withdrawn at any time. Sharing data within the service and other services will be discussed with you before any action is taken. Please tick the boxes below, where you consent for data to be shared with: Child/Young person’s Name: *