Referral Form PPC

Complete a Referral

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, I've been advised

2. Do you consent to us sharing referral information within the Medway Therapeutic Alliance (including partner organisations delivering services) to ensure the child/young person receives the most appropriate support?

Yes No

3. Do you consent to us sharing referral information with relevant external organisations (outside of the Medway Therapeutic Alliance) where this is necessary to ensure the child/young person receives the right support at the right time?

Yes No

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

Yes No

5. The parent/carer has given consent for this referral to be made

Yes No

6. Please indicate if the child/young person is over 13 and has requested that the parent/carer not be made aware of this referral or contacted

Yes No

1. Who is making this referral?

2. Referrer First Name

Referrer Surname

3. Job title/relationship to the child/young person

4. Agency organisation

5. Contact Number

6. Address Line 1

7. Address Line 2

8. City

9. County

Postcode

10. Email

Child / Young Person First Name

Child / Young Person Last Name

2. Preferred name (if different from above)

3. Date of Birth

4. Gender identity of child/young person

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

6. Is the child/young person currently questioning their sexuality?

7. Address

8. Postcode

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

10. Is an interpreter required?

11. If an interpreter is required, select the language

12. What is the family’s accommodation status?

13. What is the child/young person’s detailed ethnicity?

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

15. Name of GP Surgery

16. NHS number

Please add parent/carer details if they differ from the referrer details

Parent/Carer Name

Parent/Carer Number

Parent/Carer Email

1. Does the child/young person attend school?

2. School Type

3. School name

School name

4. Does the child/young person recieve free school meals?

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

6. Does the child/young person have a diagnosed disability?

7. 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

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

9. Allergies

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

11. Medication

1. Is the child/young person currently in care (Care Experienced)?

2. If yes, is there an allocated Social Worker?

3. Legal status under the Children’s Act

4. Name of responsible Local Authority

5. Is the child/young person a Care Leaver?

5. Is the child/young person a Refugee or Asylum Seeker?

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

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

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

9. Is the child/young person a Young Carer?

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

1. Does the child/young person currently have a Social Worker?

2. Social Worker Name

3. Social Worker Number

4. Social Worker Email

5. Social Worker Team/Service

6. Is the child/young person currently Looked After (LAC)?

7. Is the child/young person care experienced / a care leaver?

8. If yes, what type of placement?

9. Legal status under the Children Act (if known)

10. If “Other”, please specify legal status

11. Is a Personal Adviser / Leaving Care Worker involved?

12. Personal Adviser / Leaving Care Worker name

13. Personal Adviser / Leaving Care Worker Number

14. Personal Adviser / Leaving Care Worker Email

1. Please list any services or interventions previously accessed

2. What has helped in the past?

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

4. Are there any significant family stressors?

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

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

2. Emotional Wellbeing

3. Risk and Safety

Please select all relevant risk concerns

4. Behaviour Concerns

Please select all relevant behavioural concerns

5. Identity and Belonging

Please select all relevant concerns

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

6. Relationships and Family

Please select all relevant concerns

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

7. If SEND/Neurodivergent

Please select all relevant 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)

8. How do the above concerns and issues impact on the child/young person at home, in education and during leisure time?

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

2. If yes, please specify the service and type of support

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

4. If yes, which service?

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

6. Please list any other professionals currently supporting the child/young person or family

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

4. Safeguarding

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

Please provide brief details

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

Please provide a brief description