Brent Centre for Young People

Brent Centre for Young People

Referral Form

Confidential

Talking Therapies for Young People aged 14-21 years
Referral Date
Name of Young Person / Male / Female
Date of Birth / / / / Age:
Address
(inc postcode)
Telephone / Mobile:
Email:
Preferred means of contact / □Home Telephone □ Mobile □ Letter □ Email
Education/Employment / □ School
□ University
□ College
□ Training / □ Unemployed
□ Employed
□ Other
Please specify______
Ethnicity / White
 English/Welsh/ Scottish/British
 Irish
 Irish Descent
 Gypsy or Irish Traveller
 Any other White background, please specify
______/ Black/African/Caribbean/Black British
 African
 Caribbean
 Any other Black /African/Caribbean background, please specify
______
Asian/Asian British
 Indian
 Pakistani
 Bangladeshi
 Chinese
 Any other Asian background, please specify ______/ Mixed/multiple ethnic groups/Other
 White and Black Caribbean
 White and Black African
 White and Asian
 Any other Mixed/multiple ethnic background, please specify
Other ethnic group
 Arab
 Any other ethnic group, please specify
______
Name of Referrer / GP’s name and Practice
Name:
Address:
Cluster: □ Harness □ Kilburn □ Kingsbury □ Wembley □ Willesden
Telephone/Email/Fax
Please note any disabilities or special needs
Current / previous medical history
Has the young person agreed to this referral and what does he/she think about the referral?
Has the young person previously been involved with any other services?
□ CAMHS / □ Assessment & Brief Treatment Team / □ Early Intervention Service / □ Youth Offending Team
□ IAPT / □ Adult & Family Psychotherapy Service / □ Social Services / □ Other
Please include copies of full assessments completed. We require the full assessment in order to process the referral.
Details of other professionals involved
Name
Job Title
Address
Telephone/Fax/Email
Date of Involvement
Reason for Referral:(please provide a summary of concerns and reasons why you are referring this person)
Family Background:(please provide a summary of young persons living arrangements, support network etc)
Risk:(Please note any past or present concerns about suicidality, self harm, substance misuse, gang affected, child protection issues, violence, or other risks)

Please note that if a young person requires psychiatric assessment you need to refer to CAMHS or Adult Mental Health Services as appropriate

I am making a referral for:

□Individual Psychotherapeutic Consultations and Assessment –

Adolescent Exploratory Therapy (AET)

This includes assessment for Psychotherapy or more intensive help

□Family Work

□Group Psychotherapy

Signature: ...... Date:

Print Name: ……………………………………………………………………………………………………..

Any Additional Information:(please provide any further details that you feel are relevant to this referral)

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Laufer House, 51 Winchester Avenue, London NW6 7TT

Registered as Brent Adolescent Centre Company No. 4037793 Charity no. 1081903