Self-Referral Form For Children & Young People’s Service

Self-Referral Form for Children and Young People's Service

If you would prefer this form in another language or in large print, or you would like to make your referral over the phone, please speak with one of our specialist administrators on either of these numbers:
York: 01904 412551
Manchester: 0161 445 2099

Do you have a preference of how you attend your appointments?*
*If you have online sessions your therapist may be based in another town so it may not be possible to see the same therapist if you decide to change from online to face to face appointments.
Which location would you prefer to attend for face to face therapy?*
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
GP Details

We cannot accept a referral without your GP's details.

Parent and Family Information

People living in the household.

If you have provided multiple parent/carer names above please provide dates of birth for all parents/carers
Educational Details
Child / Young Person's Needs
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 themselves, 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.)
Does the child/young person have or is awaiting assessment for any specific diagnoses that you feel are relevant to share?
(e.g. autism, ADHD, Downs syndrome, dyslexia, dyspraxia, sensory processing differences etc)
Is the child/young person on any medication that is relevant to share? If so, provide details.
Is your child aware of this referral at this stage? If so, what are their views?
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?
Please select all of the ways you are happy for us to contact you:
How are you funding the therapy?

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:

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

This must be completed by the parent/carer if the child is under 16 years old.

I hereby agree:

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Help in A Crisis

There are many things that can make us feel low or hopeless and these feelings can come and go but it is important to take them seriously.

If you are having thoughts of suicide, are harming yourself or have thoughts about self-harm it is important to tell someone.

These thoughts and feelings can be complex, frightening, and confusing but you do not have to struggle alone.

Whilst The Retreat Clinics is not able to provide crisis services, if you feel unable to cope or keep yourself safe, please contact your GP immediately, or contact an organisation who specialises in crisis support. We have listed some organisations below who may be able to help you.

NHS Foundation Trust – all people of all ages

Website: Mental Health Helpline for Urgent Help - NHS (
Available 24 hours

SHOUT crisis support

Mental health support by text message
You can text "SHOUT" to 85258 for free from all major UK mobile networks. You'll then be connected to a volunteer for an anonymous conversation by text message. This is a free, confidential, 24/7 text messaging mental health support service.

Samaritans – all people of all ages

Call: 116 123
Available 24-hour
Area: UK Nationally

Campaign Against Living Miserably (CALM) - Men

Call: 0800 58 58 58
Available 5pm to midnight every day – Cover National
Area: UK Nationally

Papyrus - people under the age of 35

Call: 0800 068 41 41
Text: 07860 039967
Available Monday to Friday 9am to 10pm, weekends and bank holidays 2pm to 10pm
Area: UK Nationally

Childline – people under the age of 19

Call: 0800 11 11
Online chat:
Available 24-hour
Area: UK Nationally