Suffolk Children and Young People’s Emotional Wellbeing Hub
Parent/Carer (for a person 0-25 years) & Professionals (for a person 18-25)
This form is designed for parents, carers, practitioners and other concerned adults who are seeking support from the Emotional Wellbeing Hub regarding a child or young person’s mental health or emotional wellbeing. The Hub is for children and young people aged 0-25 who are registered with a GP in East or West Suffolk. Please ring the following number if you would like additional information prior to submitting a referral:
Telephone: 0345 600 2090, Monday to Friday 8am – 7:30pm
For a medical emergency, dial 999.
1. Initial Screening
Please tick any that apply:
Requires an urgent response from the Hub
Requires assessment for First Episode Psychosis
Requires assessment for Eating Disorders
Please give additional details if you have ticked any of the boxes above:
2. Details of the concerned adult or referring professional
First Name:
Surname:
Role/relationship to the young person:
Service/team/organisation (if applicable):
Home/office phone number:
Mobile phone number:
Email address:
Address line 1:
Address line 2:
Town:
Postcode:
Consent: Please confirm that the person with parental responsibility (or the young person if they are aged 16+) consent to you sharing information with the Emotional Wellbeing Hub:
Yes
No
3. Details of the child or young person
Title:
Please Select A Value...
Master
Mr
Mrs
Miss
Ms
First Name:
Surname:
Date of birth:
How does the young person identify their gender?
Female
Male
Other
Prefer not to answer
If you selected ‘Other’, please tell us how the young person describes their gender identity:
Ethnicity:
Please Select A Value...
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 Stated - Not Stated
Not known - Not known
Home phone number:
Mobile phone number:
Address line 1:
Address line 2:
Town:
Postcode:
School or educational placement:
Name of Registered GP:
Registered GP practice:
NHS Number (if known):
4. Emotional Wellbeing
Presenting Problem: Who is worried about the young person’s wellbeing at the moment and what are the main concerns?
History (including medical history): How long has this problem been around? What has happened in the past that contributes to the concern?
What is the impact of the problem on the child or young person’s daily functioning?
How are things going at school (or at work), at home in the family and with friends?
Please describe any complicating factors that make the problem(s) harder to deal with.
What is working well? What strengths or resources are available to this young person and their family or network?
What do you think needs to happen next to address these concerns?
5. Safety
On a scale from 0 to 10, how safe is this young person at the moment?
Please Select A Value...
0 - she or he will definitely come to serious harm
1
2
3
4
5
6
7
8
9
10 - she or he will manage to stay safe
Summary of the risk: What are you worried will happen if nothing changes?
Risk history: What harm has already happened? (Please give dates and details)
Protective Factors: Who or what supports safety at the moment? What prevented you from scoring any lower on the scale?
Next step: What needs to happen to move your rating one point higher up the scale?
6. Goals
In coming to this service, what would you like to be different or what are the main goals you want to get to? Please answer these questions from your own point of view (as a concerned adult) about what you would like to see change.
What is your first goal?
How close are you to reaching your first goal today?
Please Select A Value...
0 - Goal not at all met
1
2
3
4
5 - Halfway to reaching this goal
6
7
8
9
10 - Goal reached
What is your second goal?
How close are you to reaching your second goal today?
Please Select A Value...
0 - Goal not at all met
1
2
3
4
5 - Halfway to reaching this goal
6
7
8
9
10 - Goal reached
What is your third goal?
How close are you to reaching your third goal today?
Please Select A Value...
0 - Goal not at all met
1
2
3
4
5 - Halfway to reaching this goal
6
7
8
9
10 - Goal reached
7. Family Network
Contact details for family members and other important connected people (please include at least one person with parental responsibility)
Please enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address:
Please enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address:
Please enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address:
Please enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address:
Please enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address:
Please enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address:
8. Other services currently or previously involved
Please enter the service's details including the name of the service, the keyworker’s name, their phone number, postal address and when the young last had contact with this service:
Please enter the service's details including the name of the service, the keyworker’s name, their phone number, postal address and when the young last had contact with this service:
Please enter the service's details including the name of the service, the keyworker’s name, their phone number, postal address and when the young last had contact with this service:
Please enter the service's details including the name of the service, the keyworker’s name, their phone number, postal address and when the young last had contact with this service:
Anything else?
Please complete the captcha
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