CYP Neurodevelopmental Services Self-Referral Form | The Retreat Clinics
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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 hello@theretreatclinics.org.uk in order for your referral to be progressed.

Please enter the name of person completing this referral form and relationship to CYP.
Child or Young Person's Details
Provide their preferred name, if different from their full name.
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
If you have provided multiple parent/carer names above please provide dates of birth for all parents/carers
Child/Young Person's Needs
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?
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.
(e.g. autism, ADHD, Downs syndrome, dyslexia, dyspraxia, sensory processing differences etc)
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.*
(e.g. vulnerable to online abuse, physical violence, disordered eating, absconding, alcohol or drug misuse, inappropriate peer relationships, or unsafe environments etc.)
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

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:

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