Self- Referral Form 16-18 Years

This self-referral form is for a young person who is between 16-18 years of age who attends one of the secondary schools we work with.

If you have problem with filling out this referral form, your school can do it for you. Speak to your teacher or the Designated Mental Health Lead in your school.

If you are experiencing other difficulties such as:

An existing mental health diagnosis. For example, clinical depression, post-traumatic stress disorder, obsessive compulsive disorder
Eating disorder
Bereavement
High risk self-harm and currently experiencing suicidal thoughts/behaviours
Oppositional defiant behaviours and other conduct disorders
Severe ADHD and ADD
Low-functioning ASD
Moderate to severe learning difficulties
Child/young person in crisis or requiring out of hours support
Child/young person requiring substance misuse interventions

This service might not be suitable for you. Please contact your school or your GP in order to find appropriate support for you OR If you are in a crisis please call 999 or go to your nearest A&E

Self- Referral Form 16-18 Years Old

Name of the school you/your child attends?

Young person intervention (11-18 years old):

Mild to moderate anxiety: worries, irrational fears and concerns
Low mood: sadness, low motivation
Family and peer relationship difficulties
Difficulty adjusting to change and transition
Difficulty regulating emotion

Pick one or more which in your opinion are the most concerning for you

Referrers details *

First

Last

Date of referral

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone

Parent/carer or young person:

Name *

First

Last

Details of the Child/Young Person

Date of birth

Age

Home address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Religeon

Gender

School name

Year group

Mobile number

Ethnicity - Mixed/Multiple ethnic groups

White and Black African
White and Black Caribbean
White and Asian
Any other mixed background

Ethnicity - Black/Black British

Black African
Black Caribbean
Any other Black background

Any other White background

White British
Irish
Any other White background

Other ethnic groups

Rather not say
Not listed

Child protection plan

Never been subject to a child protection plan
Previously been subject to a child protection plan
Currently subject to a child protection plan
Not known

Looked after child

Accommodation status

Mainstream housing
Other (Please specify)

Other - specify here

Settled accommodation indicator

Settled accommodation
Non-settled accommodation
Not known

Special educational need or disability (SEND)

Yes
No
Don't know

Details of special educational need or disability

Does the child/young person have an Education Health and Care Plan (EHCP)?

Yes
No
Don't know

Has the child/young person had a mental health intervention before (e.g. CAMHS, school counsellor, Educational Psychologist etc.)?

Yes
No
Don't know

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?

Yes
No
Don't know

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:

Full Practice Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Details of other agencies/professionals involved:

Name, Address, Phone Number, Email, etc

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Any other agencies involved?

Name, Address, Phone Number, Email, etc

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:

A service that the client is already accessing / due to access / has recently accessed
A new service (referral) that would benefit the client (The client requires a different service from what is being offered by BWW Mind)

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:

Date / Time

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:

A service that the client is already accessing / due to access / has recently accessed
A new service (referral) that would benefit the client (The client requires a different service from what is being offered by BWW Mind)
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.

Child/Young person’s Name: *

First

Last

Date

Self- Referral Form 16-18 Years

If you are experiencing other difficulties such as:

Self- Referral Form 16-18 Years Old

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