Trailblazer Programme Mental Health Support Teams Request for support form Referrer InformationReferrer name * REQUIRED School name * REQUIREDPlease select oneAll 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 * REQUIRED Referrer Contact Telephone * REQUIREDReferrer's Email * REQUIRED If at primary school, please give the class teacher’s email address Consent InformationPlease ensure a conversation has taken place with the young person and/or their parent/carer. It is essential that the young person's voice is heard. For secondary aged young people, please ensure a conversation has been had, and consent has been given by the young person, not just the parent/carer.Has consent been given for this referral? * REQUIRED Yes, by the young person (for all referrals) Yes, by parent/carer No Has the possibility of the referral being signposted or discussed with one of our partner agencies been discussed with the young person and/or parent carer? * REQUIRED Yes - young person Yes - parent/carer Yes - both No Have you completed a Boxall Profile for this young person? * REQUIRED Yes No Young person informationFull name * REQUIRED Preferred name Date of Birth: - must be dd/mm/yyyy format * REQUIRED DD slash MM slash YYYY Gender * REQUIREDPlease SelectFemaleMaleNot specifiedSchool year * REQUIRED Religion * REQUIRED Ethnicity * REQUIRED Uk Residence StatusPlease select one:Asylum 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 * REQUIRED Interpreter required? * REQUIRED Yes No Address * REQUIRED Address Line 1 Address Line 2 City Post code Young person's school or personal email Essential for secondary school aged personYoung person's mobile numberEssential for secondary school aged personAny initial assessment will be conducted via an online virtual platform, with any following sessions either online or face to face in school. Please can you state your preference for following appointments: * REQUIRED Face to face Online Your referral may be signposted to TiC+, please incidate your preference for contact with TiC+ * REQUIRED Face to face Online Text chat Telephone GP Surgery Name * REQUIRED GP Phone numberPreferred contact for arranging appointments? * REQUIRED Directly with young person With parent/carer Preferred method of contact for arranging appointments * REQUIRED Email Leave a message with parent/carer or other person Letter home Mobile (call) Other person contact details Parent/Carer informationParent/carer full name * REQUIRED Relationship to young person * REQUIRED Parent/ carer phone number * REQUIREDEmail address Preferred language * REQUIRED Interpreter required? * REQUIRED Yes No Does this person have parental responsibility? * REQUIRED Yes No Does anyone else have parental responsibility? * REQUIRED Yes No Their full name * REQUIRED Address * REQUIRED Street Address Address Line 2 City Post code Phone * REQUIREDEmail * REQUIRED Relationship to young person * REQUIRED 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. * REQUIREDSummary 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? * REQUIREDPlease 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 include the young person's views. What has made them seek help at this time? What are their strengths? How would they like things to change? * REQUIREDDoes the young person have a disability, learning, psychological or sensory need? * REQUIRED Yes No Please state any reasonable adjustments requiredIs the young person on any medication? * REQUIRED Yes No Please provide details of the medication * REQUIREDAre there any concerns around substance misuse? * REQUIRED Yes No Please provide details of the substance misuse concernsIs the young person known to social care? * REQUIRED Declined to disclose No Yes (currently) Yes (previously) Please provide details of social care worker * REQUIREDIs the young person a young carer? * REQUIRED Declined to disclose Yes No Not known Please provide details of care responsibilities * REQUIREDDoes the young person have an Education Health and Care Plan? * REQUIRED Yes No Is the young person a Looked After Child? * REQUIRED Yes No Not known Is the young person currently/previously open to CYPS? * REQUIRED Yes (currently) Yes (previously) No Declined to disclose Does this young person have (or had previously) a Child Protection Plan? * REQUIRED Yes (currently) Yes (previously) No (never been subject to a CPP) Not known Any known self-harming behaviour in the last 3 months? * REQUIRED Yes No Not known Details of self-harming behaviour * REQUIREDAny known suicidal thoughts or acts? * REQUIRED Yes No Not known Either historical or current.Details of suicidal thoughts or acts * REQUIREDAre there any safeguarding concerns about this young person? * REQUIRED Yes No Either historical or current.Details of safeguarding concerns * REQUIREDWorking Safely
