School Public Health Service referral form

Your information

If you would like to find out what happens to personal information held about you, please read the your personal information section on our Legal page. You can also read our privacy policy for more information.

If you would like to request a general health awareness training session (anaphylaxis, epilepsy or asthma awareness) you do not need to submit a referral. Please see our Schools resource hub.

Statement on service wait times

We are currently experience a high number of referrals into the Kent School Health Counselling Service. Our wait time for assessment with one of our counsellors is approximately 18 weeks.

If your referral is of an urgent nature, or involves risk around a child or young person, please contact the single point of access for children's mental health on 0800 011 3474 to discuss your concerns.

Further advice can be found on the Kent and Medway Children's and Young People's Mental Health Service website.

Are you a ...*
Is this referral for...*
- General health
- Emotional health
Young person
Kent School Health provide a range of support services, in order that your referral is directed to the correct support, please complete this form with as much detail as possible.
We work hard to make sure your information is safe. As personal email accounts are not encrypted, there’s a very small risk that the emails sent between us could be opened and read by someone else or ‘hacked’. If you’re worried about this, we can support you to make your email communication with us extra secure. Please call us on 0300 123 5205 option two and we can help you set up a secure email communication.
Your 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.
Do you give consent to being contacted to give feedback or to complete a questionnaire?*
- Yes
- No
Your details
Your first name*
Your last name*
Your date of birth*
Your address*
Street Address Address Line 2 City County Postcode
Your gender*
Other, please specify*
Your ethnicity*
Other, please specify*
Your phone number*
Do you consent to receiving voicemail or text?*
- Yes
- No
Your email

Please note: Personal email accounts are not encrypted, there’s a very small risk that the emails sent between us could be opened and read by someone else or ‘hacked’. If you are worried about this, we can support you to make your email communication with us extra secure. You can contact us on 0300 123 5205 option 2.
What is your preferred method of communication?*
Please select more than one if required.
- Email not secure
- Email secure
- Letter
- Phone landline
- Phone mobile
- Text message
Do you have any communication or learning difficulties?*
- Yes
- No
Please give details, for example, literacy, language needs?*
Do you need an interpreter?*
- Yes
- No
Please give details, for example, language required?*
Is one of your parents, or your guardian or carer, a member of the British Armed Forces (regular, reserve and national services)?*
- Yes
- No
Are you happy for us to contact your parent/carer about your referral?*
- Yes
- No
Parent/carer details*
For example, name, relationship to you, phone number.
Your school*
If not in education please select 'Not in education' from the dropdown list.
Are you a young carer?*
A young carer is someone under 18 who helps look after someone in their family, or a friend, who is ill, disabled, has a mental health condition or drug and alcohol problem.
- Yes
- No
GP details (your doctor)
GP name/surgery
GP phone
Your reason for referral
What are you worried or concerned about?*
Please give as much detail as possible.
How long has this been worrying you?*
Does your worry stop you doing the things you enjoy?*
- Yes
- No
What does it stop you doing?*
Are you self-harming?
- Yes
- No
If yes, then please provide more details, for example, how long and how often has this been happening?*
Is anybody helping you? Are you seeing anyone else in regard to your concerns, any other services?*
Hidden
Date*
DD slash MM slash YYYY
After submitting a referral to the School Public Health Service. Your referral will be reviewed by our integrated health teams, we will aim to contact you within 20 working days.

If your concerns escalate, please contact your doctor, visit an NHS walk in centre or call NHS 111. If it is an emergency dial 999 or visit Accident and Emergency (A&E).

If you wish to discuss this referral, please contact the service on 0300 123 5205 (option 2) or kentchft.kentschoolhealth@nhs.net.

We operate Monday to Friday, 8am to 6pm and are not an emergency service, therefore (if your referral contains safeguarding information or there is a risk of harm to the young person you are referring, you should follow your internal safeguarding processes).
Parent/carer referral
Kent School Health provide a range of support services, in order that your referral is directed to the correct support, please complete this form with as much detail as possible.
We work hard to make sure your information is safe. As personal email accounts are not encrypted, there’s a very small risk that the emails sent between us could be opened and read by someone else or ‘hacked’. If you’re worried about this, we can support you to make your email communication with us extra secure. Please call us on 0800 0113 474 (option 3 – School Health) and we can help you set up a secure email communication.
Consent
Consent*
I can confirm that I have discussed this referral with my child/young person and consent to being contacted.
No, please say why*
Consent obtained from parent/carer?*
- Yes
- No, please say why
No, please say why*
Child/young person details
First name*
Last name*
Date of birth*
Age validation*
Age validation – Please confirm that this child/young person was born on or before 31/08/2019.*
Child's address*
Street Address Address Line 2 City County Postcode
NHS number
School*
If not in education please select 'Not in education' from the dropdown list.
If other school, please specify
Year group

(if applicable)
Their gender*
Other, please specify*
Their ethnicity*
Other, please specify*
Parent/carer details
Your name*
Your relationship to the child/young person*
Do you have parental responsibility for the child/young person?*
- Yes
- No
You cannot make a referral for a child if you do not hold parental responsibility.
Is your address the same as the childs?*
- Yes
- No
Your address*
Street Address Address Line 2 City County Postcode
Your phone number*
Do you consent to receiving voicemail or text?*
- Yes
- No
Your email

Please note: Personal email accounts are not encrypted, there’s a very small risk that the emails sent between us could be opened and read by someone else or ‘hacked’. If you are worried about this, we can support you to make your email communication with us extra secure. Please call us on 0300 123 5205 option 2.
What is your preferred method of communication?
Please select more than one if required.
- Email not secure
- Email secure
- Letter
- Phone landline
- Phone mobile
- Text message
Do you have any communication or learning difficulties?*
- Yes
- No
Please give details, for example, literacy, language needs?*
Do you need an interpreter?*
- Yes
- No
Please give details, for example, language required?*
Do you give consent to being contacted to give feedback or to complete a questionnaire?*
- Yes
- No
Has the child/young person been referred/or currently receiving help from other services/agencies?
For example, Early Help, Social Services, Mental Health service or any other family support service?
- Yes
- No
Please give details, for example, name, phone number, intervention, date started
Child/young person’s GP details
GP name*
GP address*
Street Address Address Line 2 City County Postcode
Questions about the child/young person
Is this child or young person a young carer?*
- Yes
- No
A young carer is someone under 18 who helps look after someone in their family, or a friend, who is ill, disabled, has a mental health condition, or drug and alcohol problem.
Does the child/young person have any communication or learning difficulties?*
- Yes
- No
Please give details, for example, literacy, language needs?*
Does the child/young person require an interpreter?*
- Yes
- No
Please give details, for example, language required?*
Is an Education Health Care Plan in Place (EHCP)?*
- Yes
- No
Has the child/young person received any previous counselling/therapeutic interventions?*
- Yes
- No
If yes please state when the intervention started/ended and what the outcome was*
Is the child/young person self-harming?*
- Yes
- No
If yes, then please provide more details, for example, how long and how often has this been happening?
Does the child/young person have a professional diagnosis for a mental health or physical health condition?*
- Yes
- No
Please give details*
Has the child/young person been referred to Kent School Health or received an intervention from Kent School Health in the last three months?*
- Yes
- No
Please give details*
Is the child/young person currently a looked after child (LAC)/Children in Care (CIC)?*
- Yes
- No
Is the child/young person dependent of a member of the British Armed Forces (regular, reserve and national services)?*
- Yes
- No
Reason for referral
What are you worried or concerned about?*
Please give as much detail as possible.
How long has this been worrying you?*
Is there anything that you have already tried to help your child/young person?*
What would you or your child/young person like to achieve as a result of this referral?*
Is anyone else helping you at the moment?
Hidden
Date*
DD slash MM slash YYYY
Your referral will now be reviewed by our integrated health teams, we will aim to contact you within 20 working days.

If you wish to discuss this further please call 0300 123 5205 option 2.
After submitting a referral to the School Public Health Service. Your referral will be reviewed by our integrated health teams, we will aim to contact you within 20 working days.

If your concerns escalate about your child, please contact your doctor, visit an NHS walk in centre or call NHS 111. If it is an emergency dial 999 or visit Accident and Emergency (A&E).

If you wish to discuss this referral, please contact the service on 0300 123 5205 (option 2) or kentchft.kentschoolhealth@nhs.net.

We operate Monday to Friday, 8am to 6pm and are not an emergency service, therefore (if your referral contains safeguarding information or there is a risk of harm to the young person you are referring, you should follow your internal safeguarding processes).
Professional referral
Kent School Health provide a range of support services, in order that your referral is directed to the correct support, please complete this form with as much detail as possible.
We work hard to make sure client information is safe. Most practitioner email accounts are not encrypted. We will therefore send information by a secure method called Egress, you will need to register for an account in order to open any correspondence we send you that contains sensitive or identifiable information. When we correspond with you in relation to a referral you will receive an email that looks like this, just click on the blue bar and it will take you to Egress in order to register for an account so you can read and respond to emails securely.
Article 6 (1) of the General Data Protection Regulation:*
Please tick one of the following to show the legal basis for referring this parent/carer/young person (KCHFT cannot process your referral unless you indicate which applies below).
- (a) Consent of the parent / carer / young person
- (b) Performance of a contract with the parent / carer / young person
- (c) Legal obligation of the data controller
- (d) Vital interests (life or death) of the parent / carer / young person
- (e) Performance of a task carried out in the public interest or in the exercise of official authority vested in the data controller
- (f) Processing is necessary for the purposes of the legitimate interest pursued by the data controller
Parent/carer/young person consent obtained*
We cannot accept any referrals without consent from the parent/carer/young person.
- Yes
- Not required - young person assessed as Gillick competent and confirm that they give consent
Is this referral as a result of a child protection conference?*
- Yes
- No
Child/young person details
First name*
Last name*
Date of birth*
Age validation*
Age validation – Please confirm that this child/young person was born on or before 31/08/2019.*
Phone (if applicable)
Does the young person consent to receiving a voicemail or text?
- Yes
- No
NHS number
Address*
Street Address Address Line 2 City County Postcode
School*
If not in education please select 'Not in education' from the dropdown list.
If other school, please specify
Year group

(if applicable)
Their gender*
Other, please specify*
Their ethnicity*
Other, please specify*
Parent/carer details
Name*
Relationship to the child/young person*
Is the address different from above?
- Yes
- No
Parent/carer address*
Street Address Address Line 2 City County Postcode
Phone*
Does the parent/carer consent to receiving a voicemail or text?*
- Yes
- No
Parent/carer's email

Please note: Personal email accounts are not encrypted, there’s a very small risk that the emails sent between us and the parent/carer could be opened and read by someone else or ‘hacked’. If they are worried about this, we can support them to make their email communication with us extra secure. Please ask them to call us on 0300 123 5205 option 2.
What is the parent/carer/young persons preferred method of communication?*
Please select more than one if required.
- Email not secure
- Email secure
- Letter
- Phone landline
- Phone mobile
- Text message
Do you have any communication or learning difficulties?*
- Yes
- No
Please give details, for example, literacy, language needs?*
Do you need an interpreter?*
- Yes
- No
Please give details, for example, language required?*
Do you give consent to being contacted to give feedback or to complete a questionnaire?*
- Yes
- No
Parental responsibility
Name*
Relationship to child/young person*
Child/young person's GP details
GP name*
GP address*
Street Address Address Line 2 City County Postcode
GP phone*
Questions about the child/young person
Is this child or young person a young carer?*
- Yes
- No
A young carer is someone under 18 who helps look after someone in their family, or a friend, who is ill, disabled, has a mental health condition, or drug and alcohol problem.
Does the child/young person have a professional diagnosis for a mental health or physical health condition?*
- Yes
- No
Please give details*
Does the child/young person have any communication or learning difficulties?*
- Yes
- No
Please give details, for example, literacy, language needs?*
Does the child/young person require an interpreter?*
- Yes
- No
Please give details, for example, language required?*
Is an Education Health Care Plan in Place (EHCP)?*
- Yes
- No
Is the child/young person self-harming?*
- Yes
- No
If yes, please provide details, for example, how long and how often has this been happening?
Are other agencies involved?*
- Yes
- No
Please include what agencies/how they are involved?*
If so, date referred/outcome of referral*
Has the child/young person been referred to Kent School Health or received an intervention from Kent School Health in the last three months?*
- Yes
- No
Please add details*
Has the child/young person been referred to social services?*
- Yes
- No
If so date referred/outcome of referral?*
Has the child/young person received any previous counselling/therapeutic interventions?*
- Yes
- No
If yes please state when the intervention started/ended and what the outcome was*
Is the child/young person currently a looked after child (LAC)/Children in Care (CIC)?*
- Yes
- No
Is the child/young person dependent of a member of the British Armed Forces (regular, reserve and national services)?*
- Yes
- No
Reason for referral
What are your worries or concerns about? Is the child/young person worried about this too?*
Please give as much detail as possible.
How long have these issues been affecting the child/young person?*
What areas of their life are currently affected?*
Please describe actions/interventions taken to support child/young person to date?*
How would you like us to support you or the child/young person?*
Referrer details
Name*
Role*
Other role*
Organisation and or Service/Team*
Address*
Street Address Address Line 2 City County Postcode
Phone*
Email*

Please note: All emails containing personal identifiable data will be sent using our secure email system Egress. If you require any support please call us on 0300 123 5205 option 2.
Hidden
Date*
DD slash MM slash YYYY
After submitting a referral to the School Public Health Service. Your referral will be reviewed by our integrated health teams, we will aim to contact you within 20 working days.

If your concerns escalate about your child, please contact your doctor, visit an NHS walk in centre or call NHS 111. If it is an emergency dial 999 or visit Accident and Emergency (A&E).

If you wish to discuss this referral, please contact the service on 0300 123 5205 (option 2) or kentchft.kentschoolhealth@nhs.net.

We operate Monday to Friday, 8am to 6pm and are not an emergency service, therefore (if your referral contains safeguarding information or there is a risk of harm to the young person you are referring, you should follow your internal safeguarding processes).

School Public Health Service referral form

Your information

Young person

Your consent

Your details

GP details (your doctor)

Your reason for referral

Parent/carer referral

Consent

Child/young person details

Parent/carer details

Child/young person’s GP details

Questions about the child/young person

Reason for referral

Professional referral

Child/young person details

Parent/carer details

Parental responsibility

Child/young person's GP details

Questions about the child/young person

Reason for referral

Referrer details