Youth Trust Self Referral
Please note - if you are referring on behalf of a young person over the age of 13, you will need to provide THEIR email details in order to complete this referral. If you do not have these details please call us on 01983 529569 to continue.
CONSENT FROM YOUNG PERSON OR PARENT/CARER
If the young person is UNDER 13 - we require the parent/carer to consent to the referral. The young person should be made aware of the referral and all those with parental responsibility must be in agreement.
If the young person is OVER 13 - if you are a parent/carer making this referral on behalf of a young person over the age of 13, please ensure you have their consent to make the referral. It is their consent we need, we do not require parental consent for young people over the age of 13.
If the young person is UNDER 13 please complete the following:
The young person is UNDER 13 and I give consent to this referral (I hold parental responsibility):
Yes
No
The young person is UNDER 13 and all those with parental responsibility are aware of the referral:
Yes
No
Is the child/young person aware of this referral?
Yes
No
If you/the young person is OVER 13 please complete the following:
I am OVER 13 and I am referring myself:
Yes
No
I am OVER 13 and my parent/carers are aware of my referral (no further details will be given to them without additional consent):
Yes
No, but I don't mind them knowing
No contact home
The young person is OVER 13 and I have their consent to make this 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 your/their 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
REFERRER’S DETAILS
If you are a parent/carer making the referral on behalf of a young person please provide your details:
Full Name:
Address:
Contact number:
Email address:
Relationship to the young person:
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:
Gender:*
Male
Female
Other
If other please provide details:
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
Pronouns:*
Please Select A Value...
She/Her/Her
He/Him/His
They/Them/Their
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
Per/Per/Pers
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
Are you (the young person):
Young carer
Fostered/ adopted (looked after child)
Pregnant
Any disabilities?:*
Yes
No
If yes, please provide details:
Any accessibility requirements?:*
Yes
No
If yes, please provide details:
If anyone attending YT sessions (or accompanying someone who is), has any access needs, please provide details here and make staff aware when booking an appointment)
Any special educational needs?*
Yes
No
If yes, please provide details:
Any other health/ long term conditions?
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:*
Landline Phone Number (if you have one):
Email address: (for young person if over 13, or parent/carer if under 13)*
If you do not have the email details, please call us instead on 01983 529569 to complete your referral.
Emergency Contact Name:*
Emergency Contact Phone Number:*
Emergency Contact Relationship:*
Please provide name and contact numbers for all those with parental responsibility (if under 13):
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
Preferred Language:*
Name of school/ college if applicable:
If you/your child attends school you may want to speak to school about the services offered by the mental health support team (MHST) based within the school setting
Registered GP surgery:*
Are any other agencies involved? (eg. CCAMHS, Social Services, Barnardo’s, Paediatrician, Health Visitor, Education Welfare):
REASON FOR REFERRAL
Please describe why you/the young person would like support (this helps us understand how best we can help you):
Reason for Referral: (tick all that apply)*
Anger
Anxiety (including social anxiety, generalised anxiety; OCD traits, health anxiety)
Behavioural issues (including risk-taking, substance misuse)
Bullying
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
School issues (including school refusal, social anxiety, exams)
Self-harming
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, the young person should be referred directly to CAMHS (01983 523602). If a young person is at immediate risk call 999.
Once we have processed your referral, we will then send a digital & wellbeing counselling agreement by email (from DocuSign). After this has been completed, you will join the waiting list for an initial assessment where we will determine the most appropriate service for you, and we will contact you as soon as we have appointments available to book. Please bear with us and call 01983 529569 or email info@iowyouthtrust.co.uk with any queries.
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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