Completed by
Date
Designation and Agency
Tel No.
Address of Referrer
Child’s Name
Date of Birth
Legal Status
Parent/Guardian’s name
Child’s address
Child’s Postcode
Parent/Guardian Tel No.
Child’s School/Nursery
GP Name
GP Address
Child’s NHS No.
Detail of Concern prompting referral/ Reason for Referral(please include information on presenting problem and impact on child and family).
What outcomes are you hoping for for this young person and their family (please indicate what you hope being seen by our service will achieve)
Significant family background/Key life events:(ie: family history of mental illness/ trauma/parental separation / physical illness / developmental concerns / delay etc)
Relevant Medical History and Details of Medication(past/current):
Please outline the support that this family has received so far with the current presenting difficulties. Please include any intervention or work undertaken by your agency to assist this child/family and that undertaken by others (please include contacts names in boxes below)
Details of other agencies involved with the family/child (past/present)
Agency / Names / Address and Tel No. / Current / Previous Involvement
Has the child/young person been seen and assessed? / YES / NO
Has the young person/family consented to this referral? / YES / NO
Do the young person/ family have any special needs/difficulties? / YES / NO
If YES, please specify
Does the young person/family need an interpreter – have any other barriers to communication / YES / NO
If YES Please specify
Information on Statutory Status
Child/young person or other child(ren)/young person(s) in family is/has been on a disability register / YES / NO
Please give details:
Child/young person has Statement of Educational Need: / YES / NO
Please give details:
Child/young person or other child(ren)/young person(s) in family is/has been on a child protection register: / YES / NO
Please give details including Category:
Child/young person or other family member(s) has/have been looked after by a local authority: / YES / NO
Please give details:
Signed:
Designation:
Forwarded to:
Copy to:
Date:
Contact Point Consent
ContactPoint is an online directory of services working with a child. Because Healthy Young Minds is defined as a ‘sensitive service’, details of the involvement with Healthy Young Minds will only be indicated with the consent of the child, young person, parent or carer.
There will be no details of which service is involved with the young person visible to practitioners, and contact must be brokered through the ContactPoint team, with the decision on whether to speak to the requesting practitioner resting with the practitioner from Healthy Young Minds.
Without inclusion on ContactPoint, other practitioners working with the child may not know that there are Healthy Young Minds practitioners with an interest in any involvement by other services, and therefore may not be included in any family support meetings or multi-agency discussions about the child and/or the family.
Do you consent to an indication of a ‘sensitive service’ being present on ContactPoint? / YES / NO
Name of person giving consent:
Relationship to child:
Signature:
Date:
PLEASE RETURN TO:
Trafford Healthy Young Minds
1st Floor Waterside House
Sale Waterside
Sale
Manchester
M33 7ZF / Telephone No. 0161 716 4747
Fax No. 0161 716 4744
We appreciate that time is an issue, so thank you very much for completing this form with as much detail as possible. This will enable us to screen the referral and respond appropriately.