Referral Form PPC - Medway Therapeutic Alliance

Complete a Referral

Referral Form

We may use the Kent and Medway Care Record (KMCR) to help inform the support we provide. If you want to find out more about use of your data in KMCR please Visit Here

1. Please tick if you have been advised to make this referral by another professional or mental health scoring tool

Yes No

If yes, please give details of who and/or which tool

2. Please state if the child and/or parent/carer are happy for us to share referral information within the Medway Therapeutic Alliance to ensure the child/young person receives the most appropriate support

Yes No

3. Please state if the child and/or parent/carer are happy for us to share referral information with relevant external services where necessary to ensure the child/young person receives the right level support at the right time

Yes No

4. The child/young person has given consent for this referral to be made

Yes No

For the questions below, please make sure you are aware of our organisation's privacy notice. View our Privacy Notice here

5. The child/young person has read the privacy notice, and understands how their information will be used and stored, or this has been explained to them in an age appropriate way

Yes

6. The parent/carer has given consent for this referral, has read the privacy notice, and understands how their child’s and their information will be used and stored

Yes – the parent/carer has given consent for this referral and read the privacy notice. No - the child/young person is over 13, and has requested that the parent/carer not be made aware of this referral

1. Source of referral

2. Who is making this referral?

3. Referrer First Name

Referrer Surname

4. Referrer job title/relationship to the child/young person

5. Referrer Agency Organisation

6. Referrer Contact Number

7. Referrer Email (An email must be provided))

8. How did you hear about this service?

9. Parent/Carer First Name

Parent/Carer Last Name

10. Parent/Carer Number

11. Parent/Carer Email

12. Can the parent/carer be informed of this referral?

1. Child / Young Person First Name

Child / Young Person Last Name

2. Preferred name (if different from above)

3. Date of Birth

4. Child/Young Person Address Line 1

5. Child/Young Person Address Line 2

6. Child/Young Person City

7. Child/Young Person Postcode

8. Child/Young Person Contact Number

9. Child/Young Person Contact Email

10. Gender assigned at birth

11. Gender identity of child/young person

12. What is the child/young person’s sexual orientation?

13. What language does the child/young person use most often?

14. Is an interpreter required?

15. Please specify language required for the interpreter

16. What is the family’s accommodation status?

17. If other, please specify other family accommodation

18. Child/Young Person's Ethnicity

19. If other, please specify other ethnicity

20. Is the child/ young person registered with a GP?

21. Name of GP Surgery

22. If other, please specify the name of the GP Surgery

23. NHS number

1. is the child/young person enroled within a school or college?

2. School Type

3. School name

School name if different

4. Please highlight if the child/young person will or has missed 15 days of school due to medical/health needs during the current academic year

5. Does the child/young person receive free school meals?

6. If yes, does the child/young person have an Educational Health Care Plan (EHCP)?

7. If not in school, please select from the below

8. Does the child/young person have additional needs or a diagnosed disability?

10. If other, please specify the other disability

11. Does the child/young person have any allergies?

12. Allergies

13. Is the child/young person currently on any medication?

14. Medication

1. Which areas best describe the main concerns? (Select all that apply)

2. Emotional Wellbeing

If other, please specify other emotional wellbeing concern(s)

3. Risk and Safety

Please select all relevant risk concerns

If other, please specify other risk and safety concerns

4. Behaviour Concerns

Please select all relevant behavioural concerns

If other, please specify other behavioural concerns

5. Identity and Belonging

Please select all relevant identity and belonging concerns

Gender identity concerns Sexual orientation concerns Social isolation Other (please specify)

If other, please specify other identity and belonging concerns

6. Relationships and Family

Please select all relevant relationship and family concerns

Relationship difficulties School attendance difficulties Family conflict Other (please specify)

If other, please specify other relationship and family concerns

7. If SEND/Neurodivergent

Please select all relevant SEND/ND concerns

Neurodivergence-related emotional distress Sensory processing difficulties impacting wellbeing Executive functioning difficulties (e.g. organisation, overwhelm) Social communication difficulties impacting relationships Distress linked to unmet SEND needs Difficulties linked to ADHD Difficulties linked to Autism Other (please specify) Other (please specify)

If other, please specify other SEND and neurodivergence concerns

1. Who lives at home with the child/young person?

2. Please list any services or interventions previously accessed

3. Are there any significant family stressors?

4. What strengths, interests or positive supports does the child/young person have?

Care leaver: A young person aged 16 or over who has previously been in local authority care and has now left care. Please note: A child who has been adopted is not considered a Child in Care or a Care Leaver.)

Currently in care: A child or young person who is being cared for by the local authority, either living with foster carers, in a children's home, or in another care arrangement.

1. Is the child/young person currently in care?

If yes, is there an allocated Social Worker?

2. Is the child/young person a care leaver?

If yes, what type of placement?

3. Social Worker Name

4. Social Worker Email

5. Social Worker Number

6. Legal status under the Children’s Act

7. Name of responsible Local Authority

Name of other responsible Local Authority, if other

8. Is the child/young person a refugee?

9. Is the child/young person an asylum seeker?

10. Is the child/young person known to Youth Justice Services or Criminal Justice System?

11. Is the child/young person currently at risk of offending?

12. Does the child/young person identify as LGBTQIA+?

13. Is the child/young person a Service Child (armed forces family)?

14. Is the child/young person a young carer?

1. Is the child/young person currently receiving any mental health or emotional wellbeing support?

If yes, please specify the service and type of support

2. Is the child/young person currently on a waiting list for any mental health service?

If yes, which service?

3. Please list any services or support previously accessed by the child or young person. This helps us plan the most appropriate care

4. Is the child/young person currently open to Early Help, Family Hub, or Family Solutions?

5. Please list any other professionals currently supporting the child/young person or family, not already mentioned within this referral

1. Does the child/young person require reasonable adjustments to access support?

Please provide a brief description of the adjustment/s

1. Is the child/young person at immediate risk/needing urgent emergency or crisis support now?

1. Self Harm

Has the child/young person self-harmed within the past 6 weeks?

If yes, when was the most recent occurrence?

Did the self-harm require professional or hospital treatment?

Please provide brief details of the most recent occurrence

2. Suicidal Intent

Has the child/young person ever made an attempt to end their life?

If yes, when was the most recent attempt?

Did the attempt require hospital treatment?

Please provide brief details

3. Suicidal Ideation

Has the child/young person expressed thoughts of not wanting to be alive?

If yes, are these thoughts current?

Please provide brief details of thoughts

4. Safeguarding

Is the child/young person in or de-escalating from a mental health crisis

Are there any current safeguarding concerns relating to this child/young person?

Please provide brief details of any safeguarding issues