Parent - Carer - Professional
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 child/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 children and young people who are struggling with their feelings.
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
• struggle with transitions or loss
• have problems with eating and food
• have trouble talking or sleeping
• feel angry or are struggling to control their behaviour or temper
• find it hard to concentrate or get on with friends
• have to check or repeat things, or worry about germs
• do not like themselves or have low self-confidence
• have other things on their mind that they struggle with.
The Be U Notts Service has also an offer for parents / carers to help them support their child / 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.
Who is making this referral?
Name:*
Are you parent/carer or professional?:*
Parent/carer
Professional
If parent/carer
Is the child / 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 child / 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 child/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
If professional
Your full name:
Role and relationship with child / young person
Job title:
Agency:
Contact number:
Email address:
Is the child / young person aware of this referral?:
Yes
No
Any information you want to add relevant to child/young person consent:
Are parents/carers aware of this referral?:
Yes
No
Any information you want to add relevant to parent/carers consent:
Child/Young Person’s Details
Title:
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
Child/YP's First Name:*
Child/YP's Last Name:*
Date of Birth:*
Address Line 1:*
Address Line 2:
Town/City:*
Postcode:*
Child / YP’s Gender:*
Female (including transwoman)
Male (including transman)
Non-Binary
Not Provided
Other (Not listed)
Child / YP’s Ethnicity:
Please Select A Value...
White - British
White - Irish
White - Any other White background
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Any other Asian background
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Any other Black background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Preferred Language:
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese and Vietnamese
Dutch
English
Farsi (Persian)
Finnish
Flemish
French
Gaelic
German
Greek
Gujarati
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Makaton (sign language)
Malayalam
Mandarin
Norwegian
Pashto (Pushtoo)
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Does C/YP have a disability?:
No Disability
Behaviour and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Other
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
Sight
Speech
Parent/Carer’s Name:*
Parent/Carer’s Address:*
Same as above
Different from child above
If 'Different from child above', please specify:
Contact details
Preferred person to contact regarding this referral:*
Parent / carer
Child / 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 Child / 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 Information
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
Other Information
Name of School / College (if applicable):
Do they know about this referral?:
Yes
No
Don't know
Does the child / young person self-harm / have suicidal thoughts?:*
Yes
No
Don't know
If Yes, what is the current presenting risk and how is this being managed at the moment?:
Does the child / young person use substances / alcohol?*
Yes
No
Don't know
If Yes, what substance(s) and how regularly?
Please briefly describe the reason for seeking help from the Be U Notts Service:*
How long have these difficulties been going on for?:*
What other support is the child/young person receiving / has been tried and with what result?:
Any other relevant information in relation to this referral:
How did you hear about the Be U Notts Service?:*
Please Select A Value...
School / teacher
Friend
Parent / carer
GP
Social worker
Online search
Other
If Other, please specify:
We will be in contact with the parent/carer or child/young person within 2 working days after receiving this form to discuss how we can help.
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