Trailblazer Programme Request for Support > Gloucestershire Health and Care NHS Foundation Trust

Referrer Information

Referrer name*

School name*

Job title*

Referrer Contact Telephone*

Referrer's Email*

If at primary school, please give the class teacher’s email address

Consent Information

Has consent been given for this referral?*

Yes
No

i.e. a conversation has taken place with the young person and, where necessary, their parent/carer.

Who gave the consent?*

Parent/carer
Young person
Both

Has the possibility of the referral being signposted to one of our partner agencies been discussed with the family?*

Yes
No

Young person information

Full name*

Preferred name

Date of Birth:*

Gender*

School year*

Religion*

Ethnicity*

Uk Residence Status

Preferred language*

Interpreter required?*

Yes
No

Address*

Address Line 1 Address Line 2 City Post code

Personal school email

Mobile number

GP Surgery Name*

GP Phone number

Preferred contact for arranging appointments?*

Directly with young person
With parent/carer

Preferred method of contact for arranging appointments*

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*

Relationship to young person*

Parent/ carer phone number*

Email address

Preferred language*

Interpreter required?*

Yes
No

Does this person have parental responsibility?*

Yes
No

Does anyone else have parental responsibility?*

Yes
No

Their full name*

Address*

Street Address Address Line 2 City Post code

Relationship to young person*

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.*

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?*

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?*

Yes
No

Please state any reasonable adjustments required

Is the young person on any medication?*

Yes
No

Please provide details of the medication*

Are there any concerns around substance misuse?*

Yes
No

Please provide details of the substance misuse concerns

Is the young person known to social care?*

Declined to disclose
No
Yes (currently)
Yes (previously)

Please provide details of social care worker*

Is the young person a young carer?*

Declined to disclose
Yes
No
Not known

Please provide details of care responsibilities*

Does the young person have an Education Health and Care Plan?*

Yes
No

Is the young person a Looked After Child?*

Yes
No
Not known

Is the young person currently/previously open to CYPS?*

Yes (currently)
Yes (previously)
No
Declined to disclose

Does this young person have (or had previously) a Child Protection Plan?*

Yes (currently)
Yes (previously)
No (never been subject to a CPP)
Not known

Any known self-harming behaviour in the last 3 months?*

Yes
No
Not known

Details of self-harming behaviour*

Any known suicidal thoughts or acts?*

Yes
No
Not known

Either historical or current.

Details of suicidal thoughts or acts*

Are there any safeguarding concerns about this young person?*

Yes
No

Either historical or current.

Details of safeguarding concerns*

Working Safely

Are you happy for YMM staff to be visiting your school?*

Yes
No

Are you happy for YMM staff to attend your school if they have been in another school that day?*

Yes
No

Do YMM staff need to wear face masks throughout your school?*

Yes
No

Can you provide a confidential space with safe social distancing within your school?*

Yes
No

Can you provide a confidential space with safe social distancing within your school?*

Yes
No

Could you provide a confidential space and a device for a CYP to access online assessment/interventions?*

Yes
No

Do you have any other comments about us working safely in your school?

Covid 19 Information

Trailblazer Programme Mental Health Support Teams

Request for support form