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 01904 412551
Child or Young Person's Details
Full name*
Date of birth*
Identified sex at birth*
Please choose
Female
Male
Prefer not to say
Other (Please State)
Identified sex at birth*
Gender the child identifies with
Please choose
Female
Male
Prefer not to say
Other (Please State)
Gender the child identifies with
Preferred pronouns
Please choose
She/Her
He/Him
They/Them
Prefer not to say
Other (Please State)
Preferred pronouns
Address*
Postcode*
Email (parent / carer)*
Mobile (parent / carer)*
Ethnic origin
GP Details We cannot accept a referral without your GP's details.
Practice name*
Address*
Phone number*
Parent and Family Information People living in the household.
Parent / carer full names*
Address (if different from above)
Relationship to person referred
In the instance where there is parental separation, please indicate if there are any contact arrangements
Please provide names and dates of birth of any siblings
Please provide the names of anyone else living in the household, and their relationship to the child being referred
Educational Details
Contact name
Address
Phone number
Please detail any concerns about education, (including additional support provided)
Does the child/young person have any learning needs? If so, provide details.
Child / Young Person's Needs
What help are you requesting for your child? Please describe.*
Is your child presenting with any self-harm or suicidal ideation? If so, please give details.*
Please choose
No
Yes
Details of child's self-harm or suicidal ideation*
Does the child/young person present a risk to themselves, others, or appear to be at risk from others?
If so, please give details.*
Please choose
No
Yes
(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*
Does the child/young person have or is awaiting assessment for any specific diagnoses that you feel are relevant to share?
Please choose
No
Yes
(e.g. autism, ADHD, Downs syndrome, dyslexia, dyspraxia, sensory processing differences etc)
Details of other assessments or diagnoses the child is waiting for
Is the child/young person on any medication that is relevant to share? If so, provide details.
Please choose
No
Yes
Details of relevant medication that the child/young person is taking
Is your child aware of this referral at this stage? If so, what are their views?
Please choose
No
Yes
Details of child/young persons views of the referral
Please describe your child’s strengths, interests, and coping strategies.
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.
How did you hear about The Retreat Clinics?
Please note any communication preferences or adaptations
Insurance Provider
Insurance Provider Membership Number
Name of funding provider
Address including postcode
Phone number
Email
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: 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
This must be completed by the parent/carer if the child is under 16 years old.
I hereby agree:
Name of parent/carer*
Relationship status
Submit
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
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.
SHOUT crisis support
Mental health support by text message
