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 SupportAll 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 emailAlthough 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 agreeThe 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.ukAre happy for us to contact you using the information you give us on this form * REQUIRED YesThe 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/crisisPlease 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 serviceName * REQUIRED First Last Gender * REQUIREDDate of birth - must be mm/dd/yyyy format * REQUIRED Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Can we contact you at this address?YesNoHome telephone numberCan we contact you on your home number?YesNoMobile phone number * REQUIREDCan we leave a voicemail? * REQUIREDYesNoSchool email address * REQUIRED Name of schoolGP surgeryEthnic originDo you care for a disabled or ill parent or older sibling?YesNoAre you in foster care?YesNoDo you have any physical or learning disabilities/health problems that we need to be made aware of?YesNoHave you spoken to someone in the YMM team using the YMM chat text serviceYesNoTo 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?NeverOnly occasionallySometimesOftenMost of the timeHave you ever had thoughts of wanting to hurt yourself?NeverOnly occasionallySometimesOftenMost of the timeHave you ever had thoughts of not wanting to be alive anymore?NeverOnly occasionallySometimesOftenMost of the timeHave you ever acted on these thoughts?NeverOnly occasionallySometimesOftenMost of the timeHow long have you been having these thoughts?NeverOnly occasionallySometimesOftenMost of the timeWhere on the happiness scale do you currently sit?1 (unhappy)2345 (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?YesNoTo 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?YesNoParent/carer name First Last Parent/carer phone numberParent/carer email address Parent/carer address - if different from yours Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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":