Youth Trust - Professional Referral
CONSENT FROM YOUNG PERSON OR PARENT/CARER
Please be aware that we will only proceed in processing this referral if we have the appropriate consent:
If the young person is UNDER 13 - We require the consent form to be signed by their parent/carer. The young person, and anyone with parental responsibility should also be informed of the referral.
If the young person is OVER 13 - We require the consent of the young person. We do not require parental consent for young people who are over 13.
If you are a professional, please discuss this referral with the child/young person and their parent(s) or carer(s). It may be necessary to share information with other professionals if Youth Trust is deemed not appropriate upon review, this is so we can offer the best service to the young person. During the course of their care, some details may be recorded digitally. For your protection, the use of this data is controlled in accordance with the Data Protection Act, 2018.
CONSENT
I agree to this referral being made. I understand that the Isle of Wight Youth Trust will be in touch with me in the future using the details provided in this form to discuss my referral, arrange appointments and arrange any onward referrals (where necessary).
Name of person giving consent:*
Date:*
Is the child or young person aware of this referral?:*
Yes
No
Are parents/carers aware of referral?:*
Yes
No
Hampshire and Isle of Wight CCG commission a number of organisations to support and treat children and young peoples’ mental health. To ensure that your referral reaches the right service to meet your needs, we may need to share your information with other organisations, which could be the Isle of Wight NHS Trust, Youth Trust or Barnardos.
Please let us know the young person's preference:*
Yes - you/they are happy for your/their information to be shared in this way
No - you/they do not want your/their information to be shared with other organisations
It may be necessary to share information with other professionals if Youth Trust is deemed not appropriate upon review, this is so we can offer the best service. During the course of care, some details may be recorded digitally. For your protection, the use of this data is controlled in accordance with the Data Protection Act, 2018.
The Isle of Wight Youth Trust will always store your personal details securely. We will use them to communicate with you in the ways you have agreed and may also use your data for administrative and analysis purposes. Our full privacy notice can be found at www.iowyouthtrust.co.uk/privacy
For full details on how we use personal data, please contact us: Youth Trust House, 114 Pyle Street, Newport, Isle of Wight PO30 1XA (01983) 529 569 info@iowyouthtrust.co.uk
YOUNG PERSON'S DETAILS
NHS Number (If known):
Title:*
Please Select A Value...
Master
Miss
Mr
Mrs
Ms
Other
First Name:*
Surname:*
Also Known as:
Pronouns:*
He / him
She / her
They / them
Gender:*
Male
Female
Other
Missing data (not recorded/not yet known)
Is gender the same as assigned at birth?*
Yes – the persons gender identity is the same gender as assigned at birth
No – the persons gender identity is not the same as their gender assigned at birth
Prefer not to say
Is the young person - (please tick all that apply):
Living with parents
Living with relative
Living with other
Looked after child
Subject to a child protection plan
Child in need
Does the young person? - (tick all that apply)
Have a disability?
Have an accessibility requirement?
Do they or parent/carer need an interpreter?
Do they or parent/carer have any access requirements?
Are they a young carer?
Are they pregnant?
If you ticked any of the above, please provide more details:
Any special educational needs?*
Yes
No
If yes, please provide details:
Date of Birth:* (DD/MM/YYYY)
Address Line 1:*
Address Line 2:
Town/City:*
County:
Postcode:*
Mobile Phone Number: (please provide if possible to help progress the referral)
Landline Phone Number:
Email address (for young person if over 13, or parent/carer if under13) - please provide if possible to help process the referral.
Ethnicity:*
Please Select A Value...
Not Stated - Not Stated
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not known - Not known
Religion:*
Please Select A Value...
Not stated
Atheist / Agnostic
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Any other religion
None
First Language:*
School/ College (if applicable):
Registered GP Surgery:*
Other Agencies Involved (eg. CCAMHS, Social Services, Barnardo’s, Paediatrician, Health Visitor, Education Welfare):
Is there a current Early Help plan etc? Please give details of Lead Professional:
PARENTS/CARERS/OTHER MEMBERS OF THE HOUSEHOLD
Please provide name, relationship to the young person, contact details and if they have parental responsibility below.
Person 1:
Does this person have parental responsibility?:
Yes
No
Person 2:
Does this person have parental responsibility?:
Yes
No
Person 3:
Does this person have parental responsibility?:
Yes
No
Any further members of the household:
REASON FOR REFERRAL
PLEASE COMPLETE EITHER YT TIER 2 OR CWP TIER 1 DEPENDING ON WHICH SERVICE YOU ARE REFERRING INTO – PLEASE ONLY CHOOSE ONE SERVICE. (PLEASE REFER TO THRESHOLD CHART ON WEBSITE FOR HELP).
YOUTH TRUST – TIER 2 SERVICE
MODERATE THRESHOLD: A moderate mental health issue is when a person has more complex symptoms that can make their daily life much more difficult than usual.
Reason for Referral: (tick all that apply)
Anxiety (including social anxiety, generalised anxiety; OCD traits, health anxiety)
Anger
Bullying
Behavioural issues (including risk-taking, substance misuse)
Depression
Eating issues
Family issues (including conflict, attachment issues, parental separation)
Gender identity
Low confidence, self-esteem and/or body image
Low mood
Peer relationships
Self-harming
School issues (including school refusal, social anxiety, exams)
Suicidal ideation (thoughts of)
Trauma (including sexual, physical & emotional abuse, domestic violence within the family, or other traumatic event).
Other (please explain below)
If Other, please explain:
If 'Suicidal ideation (thoughts of)' has been selected and there is evidence of suicide attempts or intent they should be referred directly to CAMHS/Crisis Service. If a young person is at immediate risk call 999
CWP – TIER 1 SERVICE (5-10yrs with Parent, 11-18yrs 1:1 with the young person)
MILD THRESHOLD: A mild mental health issue is when a person has a small number of symptoms that have a limited effect on their daily life. Our Child & Young People Wellbeing (CWP) Practitioners offer a range of evidence-based low intensity interventions based on cognitive behavioural therapy (CBT) and guided self-help.
Please choose one of the following – anxiety/low mood/behavioural difficulties, paying attention to the age groups we are able to work with within each category.
Anxiety (ages 5-18)
Low Mood (age11-18)
Behavioural difficulties (ages 5-10)
Anxiety (ages 5-18) – This may include: School refusal, Lack of sleep/bad dreams, Avoidance of friends or social situations, Finding it hard to concentrate, Negative thoughts or mind racing with too many thoughts, Lack of confidence to try new things, Worrying, Feelings of being nervous, restless, and edgy, Panic attacks, Difficulty managing stressful situations such as school exams or worrying about the future.
Low Mood (age11-18) – this may be connected to: Bullying, Low self-esteem, Peer relationships, Loneliness, Lacking in energy & motivation, Tired or exhausted, Irritable, feeling of sadness, Loss of enjoyment from things that used to be enjoyable, or feelings of hopelessness
Behavioural difficulties (ages 5-10) – this work is with the parents, not the child - this may include: Anger, Tantrums, Frustrations, Being short-tempered, Difficulty following instructions, Avoidance, Physically hurting others, Refusal to go to bed, Finding it hard to manage boundaries put in place e.g time spent on gaming & TV
Please explain referral details including: nature of mental health difficulties, when did these start? Frequency and duration? Impact on young person and family?:*
What is/are the current presenting risks? How is this being managed by family and professionals at current time?:*
Any relevant medical history?:*
Is the young person on current medication?:*
Are there concerns regarding substance misuse?:*
What would you like the aim of the work to be? And what would you like achieved?:*
IF YOU HAVE SAFEGUARDING CONCERNS PLEASE CONTACT HANTS DIRECT ON 0300 555 1384
ADULT SAFEGUARDING CAN BE CONTACTED FOR ADVICE THROUGH ‘ADULT FIRST RESPONSE’ ON 01983 814980.
REFERRER’S DETAILS
Full Name:*
Job Title:*
Agency:*
Address:*
Contact number:*
Email address:*
The Youth Trust is unable to provide crisis support. If you are in need of immediate support, please contact the numbers below:
If your life is at imminent risk or you need urgent medical attention – call 999 and ask for an ambulance.
If you feel that you are likely to harm yourself or are in danger of harming others, please call 111 or attend St. Mary’s Hospital A&E
There is always someone you can talk to if you need support:
If you are under 18 you can call Childline on 0800 1111 for free, they are available 24 hours a day, 365 days a year.
If you are aged over 18 you can call the Samaritans for free on 116 123, they are available 24 hours a day, 365 days a year.
Shout provides a free 24/7 text crisis support service, to start a conversation, just text the word ‘SHOUT’ to 85258. It is a confidential, anonymous service for anyone in the UK and details won’t appear on your phone bill.
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