Young person referral
Consent Your consent* I agree to being contacted by a member of the School Health Team to discuss my needs.
Your consent* I confirm that I have made this referral myself upon the understanding that what I tell the service is confidential and will not be shared with anyone else unless I say it is okay, except if my health, safety or welfare is at significant risk.
Your consent Do you give consent to being contacted to give feedback or to complete a questionnaire?
School
Reason for referral
Your details Your date of birth* Your gender* Is this the same as your sex at birth* Your address*
Are you happy for us to contact your parent/carer about your referral?*
Parent/carer details Name*
First
Last
Do they live at the same address as you?* Their address*
Communication details Do you need any communication support?* Please detail communication support*
Questions about you Are you a young carer?* A young carer is someone under 18 who has caring responsibilities for another person who is ill, disabled, has a mental health condition or drug and alcohol problems.
Do you have any special educational needs or disabilities?* Do you have an Education, Health Care Plan (EHCP)?* Are there any reasonable adjustments you need to support you to access healthcare?* For example, appointments on ground floor due to mobility, quiet waiting space.
Do you require an interpreter?* What language do you require?*
Are you a looked after child (LAC) / child in care (CIC)?* Is your social worker aware of this referral?* Do you have any social, cultural or religious beliefs that may be impacted by us providing healthcare?* For example, not usually applicable to our kind of care however, people with certain faiths could need appointments outside of specific times or having a chaperone.
Is anyone in your immediate family a current or previous serving member of the British Armed Forces?* Are you currently receiving help/support or on the waiting list for any other services / professionals?* For example, social worker, keyworker, paediatrician, counselling, Child and Adolescent Mental Health Services CAHMS.
who are you being seen by or waiting to be seen by?*
Reason for referral details What are you worried or concerned about?* Please give as much detail as possible.
What supportive measures have you tried or are in place?*
Do you have a professional diagnosis for a mental health condition?* Are you self-harming?* Have you received previous counselling / therapeutic interventions?* What would you like to achieve as a result of this referral?*
Is the child or young person...* I have discussed this referral with my child / young person and consent to being contacted* You will need to show the legal basis for referring this parent / carer / young person (KCHFT will not process your referral unless you indicate which applies below):
Article 6 (1) of the General Data Protection Regulation:* Is the child or young person...*
School
Reason for referral
Child/young person details Date of birth* Their gender identify*
Is this the same as their sex assigned at birth?* Their pronouns* If child/young person is age 13+, how would they describe their sexual orientation? Child/young person address*
Child/young person GP address*
Young person consent Young person consent obtained?* Please confirm the young person is aware of and in agreement with this referral, without this we will not be able to support you with your concerns.
Has the young person consented to their parents/carers being informed of the referral?* Why has the young person not given consent?*
Parent / carer details Parents name*
First name
Surname
Is the address the same as the child / young persons?* Address*
Parental responsibility Does the parent/carer have parental responsibility for the child/young person?* Name of person with parental responsibility*
First name
Surname
Communication This field is hidden when viewing the form
OLD Does the young person prefer not to be contacted in any of these ways please click on the relevant box This field is hidden when viewing the form
OLD Does the parent/carer prefer not to be contacted in any of these ways please click on the relevant box Does the child/young person need any communication support?* Please detail support needed for the child/young person*
Does the parent/carer have any communication or learning needs?* Please detail communication or learning needs*
Does the parent/carer require an interpreter?* Does the parent/carer consent to being contacted to give feedback or to complete a questionnaire?* Does the young person consent to being contacted to give feedback or to complete a questionnaire?* Is the child / young person a young carer?* A young carer is someone under 18 who has caring responsibilities for another person who is ill, disabled, has a mental health condition or drug and alcohol problems.
Does the child / young person have any special educational needs or disabilities?* Does this child/young person have an Education, Health Care Plan (EHCP)?* Are there any reasonable adjustments that your child requires to support them accessing healthcare?* For example, appointments on ground floor due to mobility, quiet waiting space?
Does the child / young person require an interpreter?* Is the child / young person currently a looked after child (LAC) / child in care (CIC)?* If yes, is the social worker aware of this referral?* Does child/young person or their family have any social, cultural or religious beliefs that may be impacted by us providing healthcare?* For example, not usually applicable to our kind of care however, people with certain faiths could need appointments outside of specific times or having a chaperone.
Is anyone in the child or young persons immediate family a current or previous serving member of the British Armed Forces?* For example, regular, reserve and national service.
Is the child / young person currently receiving help/support or on the waiting list for any other services / professionals?* For example, social worker, keyworker, paediatrician, counselling, Child and Adolescent Mental Health Services CAHMS.
Who are you being seen by or waiting to be seen by?*
Are there any safeguarding concerns?*
Reason for referral details What are you worried or concerned about?* Please give as much detail as possible.
How long has this been worrying you?*
What supportive measures have you tried or are in place?*
What would you like to achieve as a result of this referral?*
What is your child/young persons views on the reason for this referral?*
Referrer details Name*
First name
Surname
Health Visiting transition Date of birth* Address*
A referral can not be made without parent/carer (s) knowledge. Please confirm how the parent/carer(s) was informed* Criteria for handover Please tick all boxes that apply.
Summary of health visiting intervention*
Details of other agencies involved including names and contact details.* For example, social services. Including named practitioner and their email address and phone number. Please write none if no agency involvement.
This field is hidden when viewing the form
Outcome of triage