Referral Form

Young Somerset is not a crisis service:

By continuing with this form, I can confirm that I am not in crisis, and can keep myself safe.

We currently have a waiting list for our low intensity CBT support. After submitting this request, we aim to be in contact within 10 working days.

Please visit our website for more support: www.youngsomerset.org.uk/need-support-immediately

In emergencies please call 999 or access your local A&E department.

How did you hear about our service?:

Title:

First Name:*

Preferred Name:

Surname:*

Gender:*

Male

Female

Non binary/non conforming

Missing data (not recorded/not yet known)

Preferred Pronouns:

Ethnicity:*

Date of Birth:*

Address Line 1:*

Town/City:

County:*

Postcode:*

Preferred Contact Number:*

Preferred Contact Number Type:*

We will need to speak to you by phone this is the number we will use.

Whose Number is this?:*

Can we leave a voicemail?:*

Yes

No

Can we send a text message?:

Yes

No

Alternative Contact Number:

Can we leave a voicemail?:

Yes

No

Can we send a text message?:

Yes

No

Email Address:*

Can we send you an email?:*

Yes

No

Your Doctors Surgery/Medical Centre:

Your age:*

Under 13

13 and over

Please provide the following information if you are under 13.

Parent/carer details (this will usually be the adult you live with)

Because you are under 13 we will need your parent/carer’s agreement.

Does your parent/carer know that you are asking for support?:

Yes

No

Parent/Carer Name:

Parent/Carer Address:

Parent/Carer Phone Number:

Parent/Carer Email Address:

Please provide the following information if you are over 13.

Emergency contact details. This should be your parent or carer, we will not contact them unless there is an emergency or we are concerned that you are at risk or pose a risk to others.

Relationship to you?:

Does your parent/carer know that you are asking for support?:

Yes

No

Emergency Contact Name:

Emergency Contact Address:

Emergency Contact Phone Number:

Emergency Contact Email:

What is the main reason you are asking for support?:*

If you would like to, please tell us more about this:

How long has this been going on? (e.g 3 months):

How does this affect your day to day life? For example; friendships, family, school/college/work, hobbies and interests:

Does this affect your self-care? For example; eating, sleeping and washing routines:

Are you currently self-harming?:

Please tell us more about this for example; how do you self harm, have you ever needed medical treatment?:

Have you told a trusted adult about this?:

Yes

No

Have you tried to end your life within the last 3 months?:

Yes

No

Have you told a trusted adult about this?:

Yes

No

Do you feel at risk of harm from others currently? (adults, peers, online):

Yes

No

Have you told a trusted adult about this?:

Yes

No

How would you like Young Somerset to help?:

Where are you currently educated?:*

Please give details (for example the name of your school):*

Do you have additional need or disability? (diagnosed or awaiting assessment):

Do you have any requirements to be able to access support comfortably? (such as language, neuro divergence, sensory needs):

To be able to receive support from a Wellbeing Practitioner we need your consent for therapeutic work and your consent to hold and record information about you and the work we do with you.

I consent to working with a trainee or qualified Wellbeing Practitioner using evidence-based interventions or working with our Wellbeing Support Team on non-clinical interventions (pre and/or post clinical intervention):*

Yes

All personal data will be processed by Young Somerset (YS) and Somerset NHS Foundation Trust in accordance with the Data Protection Act 1998 & 2018 General Data Protection Regulation and in accordance with Young Somerset’s and Somerset NHS Foundation Trust Data Protection Policy and Guidelines. For full details of how we use and store your data please see our Privacy Statement and Data Protection Policy:

www.youngsomerset.org.uk

By completing this form you consent to us storing your information on our database:

I consent to my data being stored:*

Yes

By completing this form you consent to us sharing your information for the purposes outlined on the link above:

I consent to my data being shared:*

Yes

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Self Referral Form

Your Details