Self- Referral Form Under 13 Years

Name of the school you/your child attends? *

Name of the school you/your child attends?

Presenting difficulties - Parent intervention (child aged 5-11)

Common challenging behaviours
Mild to moderate anxiety: worries, irrational fears and concerns
Family and peer relationship difficulties

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

Presenting difficulties - Young person intervention (11-18 years old)

Low mood: sadness, low motivation
Mild to moderate anxiety: worries, irrational fears and concerns
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 - Asian/Asian British

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

Sexual orientation

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

Yes
No

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):

Agreement *

I certify that the information I provided is true to my knowledge and that I attend one of the 33 schools listed above and I am/my child is under 13 years old

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?

Yes
No

(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?

Yes
No

(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

If your child or you as a young person is experiencing other difficulties such as:

Self- Referral Form Under 13 Years

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