Referral Form CYP - Medway Therapeutic Alliance

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

Yes, I've been advised No, I have not 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

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

Yes No

How did you hear about this service?

First Name

Last Name

Preferred name (if different from above)

Date of Birth

Gender assigned at birth

Gender identity

Ethnicity

Sexual orientation

Address Line 1

Address Line 2

City

Postcode

Contact Number

Contact Email

Name of GP Surgery

NHS number

Do you attend school?

School Type

School name

School name (if not in the list)

If not in school, please select from the below

Do you have a diagnosed disability?

Name of disability

Have you missed 15 days of school due to medical/health needs during the current academic year

Are you currently in care (Care Experienced) or a care leaver?

If currently in care, is there an allocated Social Worker?

Are you known to Youth Justice Services or Criminal Justice System?

Are you currently at risk of offending?

Do you identify as LGBTQIA+?

Are you a Young Carer?

Are you a Service Child (armed forces family)?

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

Emotional Wellbeing

Risk and safety selection:

Please select all relevant risk concerns

Behaviour concerns

Please select all relevant behavioural concerns

Identity and Belonging

Please select all relevant identity and belonging concerns

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

Relationships & family

Please select all relevant relationships and family concerns

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

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)

How do the above concerns and issues impact on you at home, in education and during leisure time?

Self Harm

Have you 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

Have you ever made an attempt to end your life?

If yes, when was the most recent attempt?

Did the attempt require hospital treatment?

Please provide brief details

Suicidal Ideation

Have you ever expressed thoughts of not wanting to be alive?

If yes, are these thoughts current?

Please provide brief details

What language do you use?

Is an interpreter required?

Yes No

Do you require reasonable adjustments?

CYP Referral Form

Referral Form