Referral Form CYP - Medway Therapeutic Alliance

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CYP Referral Form

If you are a child/young person making a referral, please complete the form below.

Referral Form PPC

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

Yes, I've been advised

Do you consent to us storing your information to support your care?

Yes No

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

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

We may use the Kent and Medway Care Record (KMCR) to help inform the support we provide... If the child and/or parent/carer would like to opt-out of this, please tick this box

Yes, I'd like to opt out

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

Yes

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

Who is making this referral?

Child / Young Person name

Preferred name (if different from above)

Date of Birth

Gender identity of child/young person

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

Is the child/young person currently questioning their sexuality?

Address

Postcode

Name of GP Surgery

NHS number

Does the child/young person attend school?

School Type

School name

If not in school, please select from the below

Does the child/young person have a diagnosed disability?

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

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

If yes, is there an allocated Social Worker?

Is the child/young person a Care Leaver?

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

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

Does the child/young person identify as LGBTQIA+?

Is the child/young person a Young Carer?

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

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

Emotional Wellbeing Risk & Safety Behavioural Concerns Identity & Belonging Relationships & Family Neurodivergence & SEND

Emotional Wellbeing

Please select all emotional wellbeing concerns that apply

Depression Low Mood Anxiety OCD Phobias Significant Trauma PTSD Bereavement / Loss Emotional regulation difficulties Anger difficulties Self-esteem / confidence Eating / body image concerns Mild emotional wellbeing concerns Seeking advice and better understandng of wellbeing Other (please specify)

Risk and safety selection:

Please select all relevant risk concerns

Self-harm behaviours Suicidal thoughts Suicidal Intent In crisis Other (please specify)

Behaviour concerns

Please select all relevant behavioural concerns

Conduct difficulties Attachment difficulties Behaviours that challenge Self-care difficulties Other (please specify)

Identity and Belonging

Please select all relevant concerns

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

Relationships & family

Please select all relevant concerns

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

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)

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

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

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

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

What language does the child/young person use?

Is an interpreter required?

Yes No

Does the child/young person require reasonable adjustments?