Trailblazer Programme Mental Health Support Teams Request for support form Referrer InformationReferrer name*School name*All Saints AcademyAylburton C of E Primary SchoolBarnwood Park Arts CollegeBeech Green Primary SchoolBelmont SchoolBerry Hill Primary SchoolBlakeney Primary SchoolBromesberrow St Mary's C of E Primary SchoolCalton Primary SchoolCatholic School of St Gregory the GreatCheltenham Bournside School and Sixth Form CentreChosen Hill SchoolCleeve Secondary SchoolCoalway Junior SchoolDene Magna SchoolDrybrook Primary SchoolDunalley Primary SchoolElmbridge Primary SchoolFive Acres High School (formerly Lakers)Forest View Primary SchoolGardners Lane Primary School (Federation w/ Oakwood)Glebe Infants (Newent Federation of Schools)Glenfall Community Primary SchoolGLOSCOL - NEW Forest of Dean CollegeGloucester AcademyHarewood Junior SchoolHeart of the ForestHenley Bank High SchoolHillview Primary SchoolHolmleigh Park High SchoolHope Brook C of E Primary SchoolHuntley C of E Primary SchoolKingsholm C of E Primary SchoolKingsway PrimaryLakeside Primary SchoolLonglevens Junior SchoolLydbrook Primary SchoolLydney C of E Community SchoolMitcheldean Endowed Primary SchoolMoat Primary AcademyNewent Community School and Sixth Form CentreOakwood Primary (Federation wi/ Gardners Lane)Parkend Primary SchoolPicklenash Junior School (Newent Federation of Schools)PillowellPittville Secondary SchoolPrimrose Hill C of E Primary Academy SchoolRibston Hall High SchoolRobinswood Primary AcademyRowanfield Junior SchoolRuardean C of E Primary SchoolSevern Vale SchoolSir Thomas Rich’s SchoolSoudley Primary SchoolSpringbank Primary AcademySt Briavels Parochial C of E Primary School (Wye Forest Federation)St James C of E Junior SchoolSt James' Primary SchoolSt John's C of E AcademySt Pauls C of E Primary SchoolSt Peter’s Catholic School and sixth form centreSt Thomas More Catholic Primary SchoolSt White's Primary SchoolThe Dean AcademyThe Forest High SchoolTredworth Junior SchoolWalmore Hill Primary SchoolWaterwells Primary AcademyWidden Primary SchoolWoodside Primary SchoolWoolaston Primary SchoolWyedean School and Sixth Form CentreYorkley Primary SchoolJob title*Referrer Contact Telephone*Referrer's Email* If at primary school, please give the class teacher’s email address Consent InformationHas consent been given for this referral?*YesNoi.e. a conversation has taken place with the young person and, where necessary, their parent/carer.Who gave the consent?*Parent/carerYoung personBothHas the possibility of the referral being signposted to one of our partner agencies been discussed with the family?*YesNoYoung person informationFull name*Preferred nameDate of Birth:* Gender*Please SelectFemaleMaleNot specifiedSchool year*Religion*Ethnicity*Uk Residence StatusAsylum seekerNon UK resident (lived in UK less than 6 months)Overseas studentPrivate patientRefugeeUK resident (lived in UK for at least the last 6 months)Preferred language*Interpreter required?*YesNoAddress* Address Line 1 Address Line 2 City Post code Personal school emailMobile numberGP Surgery Name*GP Phone numberPreferred contact for arranging appointments?*Directly with young personWith parent/carerPreferred method of contact for arranging appointments*EmailLeave a message with parent/carer or other personLetter homeMobile (call)Other person contact detailsParent/Carer informationParent/carer full name*Relationship to young person*Parent/ carer phone number*Email address Preferred language*Interpreter required?*YesNoDoes this person have parental responsibility?*YesNoDoes anyone else have parental responsibility?*YesNoTheir full name*Address* Street Address Address Line 2 City Post code Relationship to young person*Household InformationWho else is living in the house?Please give the name, date of birth (if known), school attending (if applicable) and relationship to the young person for each person living in the household.* Summary of presenting needsPresenting difficulties Worry/anxiety Low mood Phobia Emotional regulation Behaviour (children under 10) Sleep Repetitive behaviours Please tick appropriate option(s)Please give a description of the young person's current emotional or mental health difficulties, indicating the frequency/severity of these behaviours and difficulties and how these are impacting on the child, family or their education. Please try to include the young person's view as well as yours, and the parents/carers if appropriate. When was the difficulty first noticed? Would you describe it as mild or moderate? What has been tried before in terms of support? Are there multiple agencies involved? Are there any communications challenges that might interfere with treatment (including for the parents)? Are you aware of any complex needs eg eating disorder, PTSD, significant trauma or risk?* Please give your desired outcomes/changes for this young person following support from the Mental Health Support Team should the referral be deemed appropriate for this service. Please try to include the young person's views. Would they benefit from peer group mentoring or a workshop to gain awareness of mental health issues and available support? What has made them seek help at this time? What are their strengths?* Does the young person have a disability, learning, psychological or sensory need?*YesNoPlease state any reasonable adjustments required Is the young person on any medication?*YesNoPlease provide details of the medication* Are there any concerns around substance misuse?*YesNoPlease provide details of the substance misuse concerns Is the young person known to social care?*Declined to discloseNoYes (currently)Yes (previously)Please provide details of social care worker* Is the young person a young carer?*Declined to discloseYesNoNot knownPlease provide details of care responsibilities* Does the young person have an Education Health and Care Plan?*YesNoIs the young person a Looked After Child?*YesNoNot knownIs the young person currently/previously open to CYPS?*Yes (currently)Yes (previously)NoDeclined to discloseDoes this young person have (or had previously) a Child Protection Plan?*Yes (currently)Yes (previously)No (never been subject to a CPP)Not knownAny known self-harming behaviour in the last 3 months?*YesNoNot knownDetails of self-harming behaviour* Any known suicidal thoughts or acts?*YesNoNot knownEither historical or current.Details of suicidal thoughts or acts* Are there any safeguarding concerns about this young person?*YesNoEither historical or current.Details of safeguarding concerns* Working SafelyAre you happy for YMM staff to be visiting your school?*YesNoAre you happy for YMM staff to attend your school if they have been in another school that day?*YesNoDo YMM staff need to wear face masks throughout your school?*YesNoCan you provide a confidential space with safe social distancing within your school?*YesNoCan you provide a confidential space with safe social distancing within your school?*YesNoCould you provide a confidential space and a device for a CYP to access online assessment/interventions?*YesNoDo you have any other comments about us working safely in your school?