Trailblazer Programme Mental Health Support Teams

Request for support form

Referrer Information
Referrer name * REQUIRED
School name * REQUIRED
Job title * REQUIRED
Referrer Contact Telephone * REQUIRED
Referrer's Email * REQUIRED
If at primary school, please give the class teacher’s email address
Consent Information
Has consent been given for this referral? * REQUIRED
- Yes, by the young person
- Yes, by the parent/carer
- No
i.e. a conversation has taken place with the young person and/or their parent/carer.
Who gave the consent? * REQUIRED
- Parent/carer
- Young person
- Both
Has the possibility of the referral being signposted or discussed with one of our partner agencies been discussed with the family? * REQUIRED
- Yes
- No
Have you completed a Boxall Profile for this young person? * REQUIRED
- Yes
- No
Young person information
Full name * REQUIRED
Preferred name
Date of Birth: - must be dd/mm/yyyy format * REQUIRED
Gender * REQUIRED
School year * REQUIRED
Religion * REQUIRED
Ethnicity * REQUIRED
Uk Residence Status
Preferred language * REQUIRED
Interpreter required? * REQUIRED
- Yes
- No
Address * REQUIRED
Address Line 1 Address Line 2 City Post code
Personal school email
Mobile number
Would you prefer to be seen face to face in school or via an online virtual platform? * REQUIRED
- Face to face
- Online
GP Surgery Name * REQUIRED
GP Phone number
Preferred 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 information
Parent/carer full name * REQUIRED
Relationship to young person * REQUIRED
Parent/ carer phone number * REQUIRED
Email 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
Relationship to young person * REQUIRED
Household Information
Who 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. * REQUIRED
Summary of presenting needs
Presenting 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? * REQUIRED
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? * REQUIRED
Does the young person have a disability, learning, psychological or sensory need? * REQUIRED
- Yes
- No
Please state any reasonable adjustments required
Is the young person on any medication? * REQUIRED
- Yes
- No
Please provide details of the medication * REQUIRED
Are there any concerns around substance misuse? * REQUIRED
- Yes
- No
Please provide details of the substance misuse concerns
Is the young person known to social care? * REQUIRED
- Declined to disclose
- No
- Yes (currently)
- Yes (previously)
Please provide details of social care worker * REQUIRED
Is the young person a young carer? * REQUIRED
- Declined to disclose
- Yes
- No
- Not known
Please provide details of care responsibilities * REQUIRED
Does 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 * REQUIRED
Any known suicidal thoughts or acts? * REQUIRED
- Yes
- No
- Not known
Either historical or current.
Details of suicidal thoughts or acts * REQUIRED
Are there any safeguarding concerns about this young person? * REQUIRED
- Yes
- No
Either historical or current.
Details of safeguarding concerns * REQUIRED
Working Safely

Covid 19 Information

Trailblazer Programme Mental Health Support Teams

Request for support form

Referrer Information

Consent Information

Young person information

Parent/Carer information

Household Information

Summary of presenting needs

Working Safely