Referral Form

Children or Young Person (CYP) Details:

Title:

First Name:*

Preferred name:

Surname:*

Address Line 1:*

Town/City:

County:*

Postcode:*

Date of Birth:*

Gender:*

Non binary/non conforming

Male

Female

Missing data (not recorded/not yet known)

Ethnicity:*

Access requirements (physical disability, learning disability, language, literacy, neuro diversity):*

Where is the CYP receiving their education?:*

Please specify which school/college if appropriate:*

CYP Email address:*

Preferred Phone Number:*

Preferred Phone Type:*

GP Name:*

GP Address:*

What is the main presenting difficulty?*

Please describe:*

Are there any secondary difficulties?:*

How long has the CYP been presenting with these difficulties?:*

How is this affecting the CYP’s daily life?:*

Is the CYP struggling to attend school/college/work?:*

Has the CYP harmed themselves in the last 3 months? (please give details):*

Is there any recent or past history of harm/aggression towards others?:*

How would you like Young Somerset to help?:*

Is the CYP currently accessing support? (please give details):*

Has the CYP previously accessed support? (please give details):*

Have there been any significant life events? Trauma, family complexities, bereavement etc (please give details):*

Young person voice. How do they view the difficulties, how does this affect them, what do they think may help?:*

Parent voice. How do they view the difficulties, how does this affect them, what do they think may help?:*

Name:*

Address:*

Postcode:*

Telephone Number:*

Email Address:*

Relationship to the CYP:*

Name:*

Work Address:*

Contact Number:*

Email Address:*

What is your professional role?:*

What is the organisation that you work for?:*

Low intensity cognitive behavioural therapy (LI-CBT) requires a commitment on the part of the child or young person to engage, complete the practice tasks and attend every session for the therapy to be successful. Therapy should be completed within a 6-8 week time frame.

If children and young people do not attend their sessions then it will be considered that LI-CBT is not suitable for them at this time and they will be discharged.

Do you consider that the child/parent will be able make this commitment?:*

Yes

The young person, their parent or carer has agreed to this request for support being made on their behalf:*

Yes

The young person, their parent or carer have consented to their data being stored in accordance with our data protection policy:*

Yes

The young person and their parent or carer have consented to their referral being transferred to MHST if they attend an MHST school:*

Yes

The young person and their parent or carer have agreed for this referral to be shared with the school's mental health lead if the child attends an MHST school:

Yes

No

If the child attends an MHST school, are they happy to attend appointments in school?:

Yes

No

The young person, their parent or carer have given permission for us to contact them by:*

Email

Telephone

Text

The young person, their parent or carer have given permission for a voicemail message to be left:*

Yes

No

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

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Professional Referral Form

Children or Young Person (CYP) Details:

Reason for referral: – to avoid a delay, please answer all questions fully

Referral Details:

Parent/Carer Details:

Your Details: