Referral Form

About this referral

If you require immediate help, please call 999 / attend A&E or contact the Mental Health 24/7 Support Line (0808 196 3779). Further contact details can be found here: https://www.beusupport.co.uk/urgent-help/

This form is for parents/carers/professionals who want to arrange advice or support for a young person (age under 25) with a Nottingham City or Nottinghamshire County GP (excluding Bassetlaw – please use http://nottalone.org.uk/ to identify the local services available in this area).

Please call us on 0115 708 0008 if you need help with making your referral.

The Be U Notts Service is here to give information, advice and support to young people who are struggling with mild to moderate mental health difficulties.

For example, they may:

• feel sad or hopeless

• have problems with family, friends or at school

• hurt themselves or have thoughts about hurting themselves

• feel anxious and scared

• have trouble sleeping

• feel angry or are struggling to control their behaviour or temper

• find it hard to concentrate

• find it hard building or maintaining relationships with friends

• have lots of worries

• do not like themselves or have low self-confidence

• have other things on their mind that they find difficult.

The Be U Notts Service has also an offer for parents / carers to help them support their young person.

After you have submitted this form, we will be in contact to discuss how we can help. We are currently experiencing huge demand for our services and are working hard to respond as quickly as possible.

Date:

Name:*

Are you a parent/carer or a professional?*

Parent

Professional

Is the young person aware of this referral?

Yes

No

So we can give you accurate and appropriate advice and support, we sometimes need to share the details you have provided with others such as your GP Practice, school, social work or any other services relevant to the support you and your young person might need.

By sending this referral form:

⬩ You give consent for the Be U Notts Service to share your details with relevant professionals /organisations to give you accurate and appropriate support.

You may withdraw this consent at any time, by writing to the Be U Notts Service Manager and asking for your referral to be cancelled. This will mean you / your young person will be discharged from the service and your referral will be closed on our secure patient database.

⬩ You agree that information provided will be stored on a secure Be U Notts database for a minimum of 2 years and to be used anonymously for monitoring purposes.

I agree:

Yes

No

Your full name:

Role and relationship with young person

Job title:

Agency:

Contact number:

Email address:

Is the young person aware of and consented to this referral?:*

Yes

No

Any information you want to add relevant to young person consent:

If No, please explain why this referral is being made without consent:

Are parents/carers aware of and consented to this referral?:*

Yes

No

Any information you want to add relevant to parent/carers consent:

If No, please explain why this referral is being made without consent:

Title:

Young Person's First Name:*

Young Person's Last Name:*

Preferred/Chosen Name (If different from above):

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

Postcode:*

Young Person’s Gender:*

Young Person’s Ethnicity:*

Preferred Language:*

Does young person have an Autism diagnosis or are they on the Autism assessment pathway?*

Yes

No

Does the young person have an EHCP?

Yes

No

If yes please provide more details:

Does the young person have any SEN Needs?

Yes

No

If yes please provide more details:

Parent/Carer’s Name:*

Parent/Carer’s Address:*

Same as above

Different from child above

If 'Different from young person above', please specify:

Preferred person to contact regarding this referral:*

Parent / carer

Young person

If Parent/carer:

Mobile Number:

Is it ok to leave a message?:

Yes

No

Is it ok to send a text?:

Yes

No

Email Address:

Preferred method of contact:

Phone

Text

Email

If young person:

Mobile Number:

Is it ok to leave a message?:

Yes

No

Is it ok to send a text?:

Yes

No

Email Address:

Preferred method of contact:

Phone

Text

Email

GP’s Name:

GP's Phone Number:

GP’s Address:

Does the GP know that you’re making this referral?:*

Yes

No

Don't know

Name of School / College (if applicable):*

Please provide details on school attendance:

Do they know about this referral?:*

Yes

No

Don't know

Is Young Person open to or known by social services?:

Yes

No

If Yes

Is Young Person a looked after child (is there a care order):

Yes

No

Is the young person subject to Child In Need Plan?:

Yes

No

Is the young person subject to child protection plan?:

Yes

No

Name of Social Worker and contact details: (if applicable)

Does the Social Worker know about this referral?:

Yes

No

Don't Know

Does the young person self-harm?*

Yes

No

Don't know

Does the young person have suicidal thoughts or attempted to end their life?*

Yes

No

Don't know

If yes: what is the current presenting risk, frequency/severity and how is this being managed at the moment?:

Is there a safety plan currently in place?:

Yes

No

Does the young person use substances / alcohol?*

Yes

No

Don't know

If Yes, what substance(s) and how regularly?

Please describe what you currently struggle with and how this impacts you on a daily basis? (consider impact on school, social life, family, relationships, sleep, eating etc)*

How long have you felt this way? Did anything happen to lead to this change?*

Is the young person waiting for or receiving treatment from any other mental health professionals/services?*

What other support is the young person receiving / has been tried and with what result? & How long was this tried for?:

Any other relevant information in relation to this referral:

How did you hear about the Be U Notts Service?:*

If Other, please specify:

We will be in contact with the parent/carer or young person within 2 working days after receiving this form to discuss how we can help.

Please complete the captcha

Parent - Carer - Professional

About this referral

Who is making this referral?

If Parent

If Professional

Young Person’s Details

Contact details

GP Information

Other Information