CYP Neurodevelopmental Services Self-Referral Form

Self-Referral Form for Children and Young People's Neurodevelopmental Services

If you would prefer our form in another language or in large print, please contact us on 01904 412551, choose option 2 and speak with one of our specialist administrators.

Please note, you will need to forward a GP referral letter to cypinfo@theretreatclinics.org.uk in order for your referral to be progressed.

I confirm that I understand that I must forward a GP referral letter to The Retreat Clinics in order for this referral to be progressed.*

Referrer name and relationship to child*

Please enter the name of person completing this referral form and relationship to CYP.

Child or Young Person's Details

Full name*

Preferred name

Provide their preferred name, if different from their full name.

Date of birth*

Identified sex at birth*

Gender the child identifies with

Preferred pronouns

Address*

Postcode*

Email (parent / carer)*

Mobile (parent / carer)*

Ethnic origin

Please select all of the ways you are happy for us to contact you:

Telephone

Text

Letter

Voicemail

Please note any communication preferences or adaptations

GP Details

Practice Name*

Practice Address*

Practice Telephone Number*

School Details - We will require a teacher to complete a diagnostic questionnaire and possibly provide further information.

Contact Name and Role*

School Address*

School Telephone Number*

Please provide an email address for your child’s teacher. If this is not possible, please provide an email address for the school.*

Please detail any concerns about education (including additional support provided)

Does the child/young person have any learning needs? If so, provide details.

This child has an Education and Health Care plan

Do you consent to us contacting your child's school for further information?

Parent and Family Information

Parent / carer full names*

Parent / carer dates of birth*

If you have provided multiple parent/carer names above please provide dates of birth for all parents/carers

Address (if different from above)

I confirm that all of the parent(s) with legal responsibility for the child have consented to this referral.*

In the instance where there is parental separation, please indicate if there are any contact arrangements

Please provide details of siblings

Child/Young Person's Needs

What has prompted you to seek an ADHD assessment for your child?*

Please include examples of behaviours and how this impacts your child at home, educational environment and socially as well as information from any other professionals and how long the difficulties have been present. Please include as much detail as possible to support the referral process.

Is your child aware of this referral at this stage? If so, what are their views?

Details of child/young persons views of the referral

Please describe your child’s strengths, interests, and coping strategies.

Does your child always seem "restless" and like they're always "on the go"? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Details and examples of how child/young person seems restless

Does your child fidget or get up when asked to sit still? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Details and examples of how child/young person fidgets or gets up when asked to sit still

Is your child easily distractible? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Details and examples of how child/young person is easily distractible

Does your child often lose things or forget things? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Details and examples of how child/young person loses or forgets things

Do you have any concerns about your child's organisational skills? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Details and examples of concerns about child/young person's organisational skills

Does your child ever blurt out answers or interrupt others when talking? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Details and examples of child/young person blurting out answers or interrupting others when talking

Does your child have difficulty waiting their turn? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Details and examples of child/young person having difficulty waiting their turn

Does your child get easily angry or frustrated? And have they ever lashed out at others? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Details and examples of child/young person getting easily angry/frustrated

Does your child ever have difficulties with (or want to challenge) people with authority such as parents, teachers, police etc? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Details and examples of child/young person having difficulties with or wanting to challenge people with authority

Does the child/young person have any co-existing physical and/or mental health difficulties or specific diagnoses? If so, please give details.

Details of other difficulties or diagnoses the child/young person has

Is the child/young person awaiting assessment for a diagnoses? If so, please give details.

(e.g. autism, ADHD, Downs syndrome, dyslexia, dyspraxia, sensory processing differences etc)

Details of other assessments or diagnoses the child is waiting for

Is your child presenting with any self-harm or suicidal ideation? If so, please give details.*

Details of child's self-harm or suicidal ideation*

Does the child/young person present a risk to others or appear to be at risk from others? If so, please give details.*

(e.g. vulnerable to online abuse, physical violence, disordered eating, absconding, alcohol or drug misuse, inappropriate peer relationships, or unsafe environments etc.)

Details of child's risk to self or others, or risks posed by others*

Is the child/young person on any medication that is relevant to the referral? If so, provide details.

Details of relevant medication that the child/young person is taking

Equality Diversity and Inclusion (EDI) Information

Is there any information you would like us to be aware of to help us meet your child/young person’s needs?

Please let us know if we need to be aware of any adjustments that might be needed.

Professionals Currently Or Previously Involved

Other professionals currently or previously involved.

This child is currently subject to a Child Protection Plan, Child in Need Plan or FEHA (Family Early Help Assessment) or have been in the past.

How did you hear about The Retreat Clinics?

Social Media

Web Search

Word Of Mouth

Radio Advert

Recommended by GP

Recommended by Educational Setting

Other (Please State)

How did you hear about The Retreat Clinics?

Consent

The Retreat Clinics can only provide a therapeutic service for your child on the basis that you have consented to this form. The process will involve collecting personal details and health care information about you and your family.

All information collected will be for the purpose of this service only and will not be shared with a third party unless we have your consent to do so or if we are legally obliged to fulfil a statutory or regulatory obligation e.g., we have received a Court Order, we are aware of a criminal offence or we must comply with a safeguarding matter.

All information will be stored on a secure encrypted network which is protected from unauthorised access through role account privileges. For further details on how we use, manage, and store your personal data please refer to our Privacy Notice. Further information can also be obtained from our Data Protection Officer.

Lawful Processing:
To provide this service to you we will need you to consent to the information below.
You can withdraw your consent at any time by contacting us at: DPO@TheRetreatYork.org.uk.

Your personal information will be retained in accordance with statutory retention guidelines as outlined in our Records Management Policy. Please note this does not affect your legal rights in terms of access, erasure and the right to objection and rectification. To find out further information about this please refer to the GDPR/Data Protection section on our website.

Consent Declaration

I hereby agree:

to my child accessing the service and confirm that I have parental responsibility to consent on behalf of my child.*

that I understand I can withdraw from this service at any time.*

Name of parent/carer*

Relationship status

If the child/young person is over 12 years of age, please tick here to indicate their consent to this referral

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CYP Neurodevelopmental Services Self-Referral Form

Self-Referral Form for Children and Young People's Neurodevelopmental Services

Child or Young Person's Details

Identified sex at birth*

Gender the child identifies with

Preferred pronouns

Please select all of the ways you are happy for us to contact you:

GP Details

School Details - We will require a teacher to complete a diagnostic questionnaire and possibly provide further information.

Do you consent to us contacting your child's school for further information?

Parent and Family Information

Child/Young Person's Needs

Is your child aware of this referral at this stage? If so, what are their views?

Does your child always seem "restless" and like they're always "on the go"? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Does your child fidget or get up when asked to sit still? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Is your child easily distractible? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Does your child often lose things or forget things? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Do you have any concerns about your child's organisational skills? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Does your child ever blurt out answers or interrupt others when talking? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Does your child have difficulty waiting their turn? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Does your child get easily angry or frustrated? And have they ever lashed out at others? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Does your child ever have difficulties with (or want to challenge) people with authority such as parents, teachers, police etc? If yes, when did you first notice this? Please can you provide some examples of this at school and at home.

Does the child/young person have any co-existing physical and/or mental health difficulties or specific diagnoses? If so, please give details.

Is the child/young person awaiting assessment for a diagnoses? If so, please give details.

Is your child presenting with any self-harm or suicidal ideation? If so, please give details.*

Does the child/young person present a risk to others or appear to be at risk from others? If so, please give details.*

Is the child/young person on any medication that is relevant to the referral? If so, provide details.

Equality Diversity and Inclusion (EDI) Information

Professionals Currently Or Previously Involved

Are any of the following professionals currently or previously involved:

How did you hear about The Retreat Clinics?

Consent

Consent Declaration