Referral Form

This form must be completed to enable a child / young person to access support from Young Somerset's Community Wellbeing Service. To access support the individual must be under 18, or up to 25 if they have an Education Health Care Plan (EHCP).

If you have any questions or require further help to complete this form please contact wellbeing@youngsomerset.org.uk

Young Somerset is not a crisis service:

By continuing with this form, I can confirm that the young person is not in crisis, and can keep themselves safe.

We currently have a waiting list for our low intensity CBT support. After submitting this request, we aim to be in contact within 10 working days.

Please visit our website for more support: www.youngsomerset.org.uk/need-support-immediately

In emergencies please call 999 or access your local A&E department.

How did you hear about our service?

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:*

Does your child have a diagnosed disability?:*

Does your child have an Education, Health and Care Plan (EHCP)?:*

Yes

No

Does your child have any access requirements?:

Is your child currently receiving support?:*

Has your child received any support within the last 12 months? Please give details such as the support received and for how long?:

Where is your child currently receiving their education?:*

Please give details (for example the name of the school):*

What is the main reason you are asking for support?:*

How long has your child been presenting with these difficulties? (eg: 3 months):*

If you would like to, please tell us more about this - When did the problem start? How does this affect your child’s day to day life? Do they self-harm or have thoughts of not wanting to be alive anymore?:

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?:

GP Name:*

GP Address:*

Your relationship to the young person:*

Name:*

Address:*

Postcode:*

Home Number:*

We will need to speak to you by phone is this the number you want us to use?:*

Yes

No

If no, please provide alternative number:

Mobile Number - Please enter a number starting 07 without any spaces:*

Can we leave a voicemail?:*

Yes

No

Can we send you text messages?:*

Yes

No

Email Address:*

Can we send you an email?:*

Yes

No

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.

The Education Mental Health Practitioners at MHST provide a similar service to the Children's Wellbeing Practitioners, however it is within the school setting. They use a whole school approach to wellbeing. You can find out more information about MHST on the Young Somerset Website: www.youngsomerset.org.uk/mental-health-support-team

I consent and my child has agreed to this referral being forwarded to the MHST if my child attends an MHST school:*

Yes

I consent and my child has agreed for this referral to be shared with the school's mental health lead if my child attends an MHST school:

Yes

No

To be able to receive support from a Wellbeing Practitioner we need your consent for therapeutic work and your consent to hold and record information about your child and the work we do with them.

I consent to myself and/or my child working with a trainee or qualified Wellbeing Practitioner using evidence-based interventions or working with our Wellbeing Navigator on non-clinical interventions (pre and/or post clinical intervention):*

Yes

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

By completing this form you consent to us storing your/your child’s information on our database:

I consent to my data being stored:*

Yes

By completing this form you consent to us sharing your/your child’s information for the purposes outlined on the link above:

I consent to my data being shared:*

Yes

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Parent/Carer Referral Form

Child/Young Person Details

GP Details

Your Details

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