Mindstars Mental Health and Wellbeing Family Support Service Referral Form
Please read the following disclaimer:
Description of programme:
Mindstars offers a group-based intervention for children aged 6-11. The children will be exploring a range of emotions, breaking them down to understand triggers, thoughts, feelings in the body and actions. The children will then develop their own resources to effectively communicate emotions at home and be tasked with practising a range of coping strategies.
Parent engagement:
Please be aware this is a family approach and parents/carers will participate in online video sessions to gain an understanding of the resources provided and how to implement these at home.
Disclaimer:
Please be aware that this is a generalised intervention, we work with children of low to moderate need and are unable to assess or diagnose. Mindstars is unable to provide interventions for specific diagnoses.
Your Email Address:*
By ticking this box, you confirm that you have read and understand the information provided in the disclaimer:*
I confirm I have read and understand the disclaimer
Referral Source
Referral source:*
Self
Organisation
If referring from an organisation please fill in the below:
Referrer Organisation:
Name of referrer:
Referrer contact email:
Referrer contact number:
Child Information
Child First Name:*
Child Last Name:*
Child Date of Birth:*
Gender
Male
Female
Do not wish to say
Missing data (not recorded/not yet known)
Do you or your child have any known disabilities?:*
Yes, myself
Yes, my child
Yes, both of us
No
If you have selected 'yes' to the above question, please specify:
Do you or your child have any specific access needs:*
Yes
No
If you have selected 'yes' to the above question, please specify:
Does your child have any known allergies?:*
Yes
No
If you have selected 'yes' to the above question, please specify:
Address Line 1:*
Town/City:*
Postcode:*
Parent/Carer Information
Parent/Carer First Name:*
Parent/Carer Last Name:*
Parent/Carer Date of Birth:*
Contact Telephone:*
Is your child subject to a Child Protection Plan?:*
Yes
No
If you have selected 'yes' to the above question, please specify:
Is your child under the care of the Local Authority?:*
Yes
No
If you have selected 'yes' to the above question, please specify:
Previous Support
Is your child currently receiving any mental health support/ interventions from other organisations? For example school, the Early Help Team, CAMHS:*
Yes
No
If you have selected 'yes' to the above question, please tick all that apply:
CAMHS
Early help team
Counsellor
Psychologist
Occupational therapist
School counsellor
Speech and language team
Social worker
Other
N/A
If you have selected 'Other', please specify:
Has your child previously received any mental health support/interventions from other organisations? For example school, the Early Help Team, CAMHS:
Yes
No
If you have selected 'yes' to the above question, please tick all that apply:
CAMHS
Early help team
Counsellor
Psychologist
Occupational therapist
School counsellor
Speech and language team
Social worker
Other
If you have selected 'Other', please specify:
Please provide details of the support previously delivered by those ticked above:
Referral Reason
Please tick all options you feel apply to your child:*
Anger/outbursts
Anxiety/worry
Behavioural related concerns
Deliberate harm to self
Deliberate harm to others
Depression
Diagnosed ADHD
Suspected ADHD
Diagnosed ASD
Suspected ASD
Diagnosed/suspected OCD
Diagnosed/suspected ODD
Diagnosed/suspected Tourette's/tick disorder
Eating disorders
In crisis
Physical/verbal aggression
PTSD
Significant attachment difficulties
Unable to recognise/manage emotions
Other
If you have selected 'Other', please specify:
Please give details of all selected above and any other information you feel is necessary for your referral:*
Additional Information
Child's School:*
Is your child currently receiving any additional support in school, for example, EHCP, EHA, additional provisions:*
Yes
No
If you selected 'yes' to the above question, please specify:
Child GP Practice:*
Parent/Carer GP Practice:*
Who directed you to our services for support?:*
CAMHS
Early Help
School
GP
Word of Mouth
Other
If you have selected 'Other', please specify:
By submitting this referral form, you consent for Mindstars to collect and store your data in accordance with appliable confidentiality laws and GDPR. Please tick to confirm:*
Yes
No
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