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?*

I prefer face to face

I prefer online appointments*

I don't mind*

*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?*

Manchester

York

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

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*

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)

Relationship to person referred

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 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.

This child has an Education and Health Care plan

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.*

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.*

(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?

(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.

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?

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.

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?

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

How are you funding the therapy?

Myself

Insurance Provider

Another Person Or Organisation

Insurance Provider

Insurance Provider Membership Number

Name of funding provider

Address including postcode

Phone number

I give The Retreat my consent to contact this person about my referral.

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

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

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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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 (www.nhs.uk)
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
Email: jo@samaritans.org
Available 24-hour
Area: UK Nationally

Campaign Against Living Miserably (CALM) - Men

Call: 0800 58 58 58
Webchat: www.thecalmzone.net/help/webchat/
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
Email: pat@papyrus-uk.org
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: www.childline.org.uk
Available 24-hour
Area: UK Nationally

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

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

Do you have a preference of how you attend your appointments?*

Which location would you prefer to attend for face to face therapy?*

Child or Young Person's Details

Identified sex at birth*

Gender the child identifies with

Preferred pronouns

GP Details

Parent and Family Information

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.*

Does the child/young person have or is awaiting assessment for any specific diagnoses that you feel are relevant to share?

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?

Consent

Consent Declaration

Help in A Crisis

NHS Foundation Trust – all people of all ages

SHOUT crisis support

Samaritans – all people of all ages

Campaign Against Living Miserably (CALM) - Men

Papyrus - people under the age of 35

Childline – people under the age of 19