Mental Health Support Team - Request for Support > Gloucestershire Health and Care NHS Foundation Trust

Search for a condition, service or location

Covid 19 Information

Please visit www.ghc.nhs.uk/coronavirus/

You can now request support to see the Mental Health Support Teams in your school. Please complete this form and hit submit. Your completed form will be looked at by the team who will then contact you via email or telephone within one working week.

YMM Request for Support

All parts of the form will be treated in complete confidentiality unless there is a concern that you or someone you know is at risk of harm. In order for us to get in touch, we’ll need you to provide a contact telephone number (either a landline or a mobile) and your school email address on the form. This information will only be used to contact you and will not be shared. * REQUIRED
- Yes, I agree to provide you with a telephone number so you can contact me
- Yes, I am happy for you to contact me by email
Although we will not share information we will need to tell a teacher or someone at the School that you have an appointment with us in order for you to be released from lessons. The reason for this appointment will be kept confidential. * REQUIRED
- I confirm I understand and agree
The data you enter into the form will be in compliance with our GDPR policy. If you’d like to understand how we look after the information you give us in a confidential way, please visit: www.ghc.nhs.uk
Are happy for us to contact you using the information you give us on this form * REQUIRED
- Yes
The Mental Health Support Teams ARE NOT A CRISIS SERVICE. If you are unsafe or if you feel unable to keep yourself safe, please do not delay getting the help you need - www.ghc.nhs.uk/crisis
Please confirm you understand this is NOT a crisis service. The team monitor referrals Monday-Friday – 9am-5pm and we will aim to contact you about your referral within 4 working days of the referral being submitted. * REQUIRED
- Yes, I understand this is not a crisis service
Name * REQUIRED
First Last
Gender * REQUIRED
Date of birth * REQUIRED
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Can we contact you at this address?
- Yes
- No
Home telephone number
Can we contact you on your home number?
- Yes
- No
Mobile phone number * REQUIRED
Can we leave a voicemail? * REQUIRED
- Yes
- No
Would you prefer to be seen face to face in school or via an online virtual platform? * REQUIRED
- Face to face
- Online virtual platform
School email address * REQUIRED
Name of school
GP surgery
Ethnic origin
Do you care for a disabled or ill parent or older sibling?
- Yes
- No
Are you in foster care?
- Yes
- No
Do you have any physical or learning disabilities/health problems that we need to be made aware of?
- Yes
- No
Have you spoken to someone in the YMM team using the YMM chat text service
- Yes
- No
To help get you the best type of support, can you tell us about what is difficult for you at the moment?
For example what difficulties are you having? How long have they been affecting you? How do they affect you/your family, school work or friends?
Has anything happened in the past or recently to make you ask for help?
For example big family changes, illnesses or the death of a loved one?
Are you worried about your own safety or the safety of somebody else?
- Never
- Only occasionally
- Sometimes
- Often
- Most of the time
Have you ever had thoughts of wanting to hurt yourself?
- Never
- Only occasionally
- Sometimes
- Often
- Most of the time
Have you ever had thoughts of not wanting to be alive anymore?
- Never
- Only occasionally
- Sometimes
- Often
- Most of the time
Have you ever acted on these thoughts?
- Never
- Only occasionally
- Sometimes
- Often
- Most of the time
How long have you been having these thoughts?
- Never
- Only occasionally
- Sometimes
- Often
- Most of the time
Where on the happiness scale do you currently sit?
- 1 (unhappy)
- 2
- 3
- 4
- 5 (very happy)
What other agencies are currently supporting you? E.g. TiC+ or social care.
Do you give us permission to contact any of the agencies supporting you?
- Yes
- No
To accept your request for counselling we prefer to have the contact details of your parent/carer. We will not contact them unless you give us permission to do so (unless we are extremely concerned about your safety or the safety of somebody else).
Do we have your permission to contact the parent/carer if necessary?
- Yes
- No
Parent/carer name
First Last
Parent/carer phone number
Parent/carer email address
Parent/carer address - if different from yours
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please provide us with a password. We will ask for the password when counselling takes place to check that the person is who they say they are. The password can be just one word that is easy to remember:
Please give us a memory jogger. If the password is forgotten this will be used to help remember it. E.g. if password is your pet's name, the memory jogger should be "pet's name":