Referral Form

The Emotional Wellbeing Hub is for children and young people aged 0-25 who are concerned about their emotional wellbeing. You can use this form to tell us about yourself, and a practitioner from the Hub will contact you to discuss your concerns with you. You can fill out as much or as little as you like, but please remember to tell us how to get in touch with you. If you prefer, you can phone the Hub on the number below and speak with one of the practitioners:

Telephone: 0345 600 2090, Monday to Friday 8am – 7:30pm

For a medical emergency, dial 999.

If you are under the age of 16, does your parent or carer know that you are contacting the Hub?

Yes

No

Can we speak to your parent or carer?

Yes

No

If we are concerned that you or someone else might get hurt, we may need to speak with other adults about it, including your parent or carer.

How are you feeling? What are you worried about?

What has happened in the past that makes you concerned?

How has this impacted on your ability to do what you need to do each day?

How are things going at school (or at work), at home, with family and with friends?

Are there people or things that make things worse?

What is working well? Are there people or things that help?

What do you think needs to happen next to address your concerns?

On a scale from 0 to 10, how safe are you at the moment?

What are you worried will happen? Who or what makes you feel unsafe?

Have you harmed yourself or has someone harmed you in the past? What happened?

Who or what helps you stay safe?

What needs to happen to help you stay safe?

In coming to this service, what would you like to be different or what are the main goals you want to get to?

What is your first goal?

How close are you to reaching your first goal today?

What is your second goal?

How close are you to reaching your second goal today?

What is your third goal?

How close are you to reaching your third goal today?

Title:

First Name:

Surname:

Date of birth:

Which best describes your gender identity?

Female

Male

Other

Prefer not to answer

If you selected ‘Other’, please tell us how you describe your gender identity:

Ethnicity:

Home phone number:

Mobile phone number:

Address line 1:

Address line 2:

Town:

Postcode:

School:

Name of your GP:

Name of GP Practice:

NHS Number (if known):

Contact details for your family members and other important people (please include your parents or carers)

Please enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address:

Please enter the service's details including the name of the service, the keyworker’s name, their phone number, postal address and when you last had contact with this service:

Anything else?

Please complete the captcha

Suffolk Children and Young People’s Emotional Wellbeing Hub

1. Emotional Wellbeing

2. Safety

3. Goals

4. Your details

5. Family network

6. Other support services you have used