Confidentiality Disclaimer
During your/the referred young person’s contact with Lincolnshire Partnership NHS Foundation Trust you/they will be asked to provide personal information to help us to deliver the best possible care.
The information provided will be kept together and form a healthcare record. Healthcare records are mainly information held on the Trust patient administration system (computer) but sometimes there are additional paper records. Every reasonable precaution will be taken to safeguard the personal information entrusted to us. Everyone working for the NHS has a legal duty to maintain the highest level of confidentiality about all patient information.
Sometimes other agencies are also involved in providing care and we may need to share information with them in order to deliver care. Anyone who receives confidential information from us is also under a legal duty of confidence. We will not disclose information outside these agencies without your/ the referred young person’s knowledge unless the health and safety of the young person or others is at risk or if we are required by law under the Data Protection Act 2018.
The referred young person has a right to see and comment on any of the information we hold about them. If you/they do have any concerns or queries about this, then please discuss this with the staff member you are in contact with. Further information about our legal basis for processing your information is detailed on our Trust website privacy policy and there is an additional leaflet How we use and share your information to help you. If you do not wish to have records accessed for research purposes please visit https://digital.nhs.uk/services/national-data-opt-out-programme to set your choices.
I confirm I have read and agree to the above Confidentiality Disclaimer
* Required
Yes
I confirm I have parental responsibility for this child/young person
* Required
Yes
If you do not have parental responsibility you can contact the Here4You line for anonymous advice.
It is important that young people aged 13 or over give consent for this referral (if they have capacity).
If they have not given consent or you are unsure if they have capacity please contact us on the Here4You line ( 0800 234 6342 ) for advice.
I confirm I have consent from my child/young person to complete this referral
* Required
I have consent from my child/ young person to complete the referral
My child is under 13
About You (the person completing the form)
Your First Name
* Required
Your Surname
* Required
Relationship to Child
We require a method of contact, by completing the field(s) below you are consenting to us contacting you in this way.
Telephone Number (You give consent for us to contact you using these details)
Email Address (You give consent for us to contact you using these details)
Do you require an interpreter?
Yes
Postal Address (if different from child/young person)
I give consent for you to send mail to this address
** None Yes No
About the Child/Young Person
Their First Name
* Required
Their Surname
* Required
Preferred name, if this is not their legal name
Their date of birth (dd/mm/yyyy)
* Required
Reason for Referral
Please describe what difficulties the child/young person is experiencing in relation to their emotional wellbeing and/or mental health?
* Required
How is this impacting on day to day life including how long they have been feeling this way? (Please consider family, relationships, school work, friends, sleep)
* Required
Is there anything else you think we should know? (Events that may have contributed to how they are feeling, things that are going well)
* Required
Are you aware of this child/young person having any thoughts around harming themselves or others. Have there been any acts of harm to self or others. Please give details.
* Required
Getting to know this child/young person further
Their pronouns are...
What sex were they assigned at birth?
* Required** None Female Intersex Male
Ethnicity
* Required** None Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Any other Asian background Black, Black British, Caribbean or African - African Black, Black British, Caribbean or African - Caribbean Black, Black British, Caribbean or African - Any other Black, Black British, or Caribbean background Mixed or multiple ethnic groups - White and Asian Mixed or multiple ethnic groups - White and Black African Mixed or multiple ethnic groups - White and Black Caribbean Mixed or multiple ethnic groups - Any other Mixed or multiple ethnic background White - Any other White background White - English, Welsh, Scottish, Northern Irish or British White - Gypsy or Irish Traveller White - Irish White - Roma Other ethnic group - Arab Other ethnic group - Any other ethnic group Prefer not to answer
If other, please specify
First language of child/young person
Do they require an interpreter?
Yes
Does this child/young person have any diagnosed long term medical conditions or disabilities?
Yes
If yes, please provide details
Child/Young Person’s Contact Information
Their Current Home Address (Required)
* Required
If this child/young person is aged 13 years or over do they agree for us to contact them by...
Telephone
Email
Their Mobile Number
Their Email Address
Healthcare
GP Surgery of Child/Young Person
* Required** None Abbey Medical Practice - Lincoln Abbeyview Surgery - Crowland Beacon Medical Practice - Chapel St Leonards Beacon Medical Practice - Ingoldmells Beacon Medical Practice - Skegness Beechfield Medical Centre - Spalding Billinghay Medical Practice Binbrook Surgery - Market Rasen Birchwood Medical Practice Bottesford Baptist Church - Bottesford Boultham Park Medical Practice - Lincoln Bourne Galletly Practice Team - Bourne Branston & Heighington Family Practice - Branston Brant Road Surgery - Lincoln Brayford Medical Practice - Lincoln Broadway Medical Centre - Mablethorpe Caistor Health Centre - Market Rasen Caskgate Street Surgery - Grantham Church Walk Surgery - Metheringham Caythorpe Surgery - Grantham Cherry Willingham (Branch Surgery) - Lincoln Cleveland Surgery - Gainsborough Cliff House Medical Practice - Burton Road Cliff House Medical Practice - Gresham Street Cliff Villages Medical Practice - Waddington Colsterworth Medical Practise - South Witham Colsterworth Surgery - Grantham Corringham Branch Surgery - Gainsborough Dr Yule-Smith And Partners - Waddingham Drs Noorpuri & Marshall - Lincoln Glebe Park Surgery - Lincoln Glenside Country Practice - Castle Bytham Glenside Country Practice - Corby Glen Gosberton Medical Centre - Spalding Greyfriars Surgery - Boston Hawthorn Medical Practice - Skegness Hawthorn Medical Practice, Burgh branch surgery - Burgh Le Marsh Hibaldstow Medical Practice - Hibaldstow Brigg Holbeach Medical Centre - Spalding Horncastle Medical Group Johnson GP centre - Spalding Kirton Medical Centre - Boston Lakeside Healthcare at Bourne, Hereward Practice Lindum Medical Practice - Lincoln Liquorpond Surgery - Boston Littlebury Medical Centre - Spalding Long Bennington Surgery - Newark Long Sutton Health Centre Long Sutton Medical Centre Marisco Medical Practice - Mablethorpe Market Cross Surgery - Corby Glen Market Rasen Surgery Marsh Medical Practice - Louth Marton Branch Surgery Merton Lodge Surgery - Alford Millview Medical Centre - Heckington Millview Medical Centre - Sleaford Minster Medical Practice - Lincoln Moulton Medical Centre - Spalding Munro Medical Centre - Pinchbeck Munro Medical Centre - Spalding Navenby Cliff Villages Surgery - Lincoln Nettleham Medical Practice Newmarket Branch - Louth North Thoresby Surgery Old Leake Medical Centre - Boston Parkside Medical Centre - Boston Portland Medical Practice - Lincoln Portland Medical Practice Branch Surgery - Newland Richmond Medical Centre - North Hykeham Ruskington Surgery Sheepmarket Surgery - Stamford Sleaford Medical Group Spilsby Surgery Springcliffe Surgery - Lincoln St Peters Hill Surgery - Grantham St.John's Medical Centre - Grantham St.Mary's Medical Centre - Stamford Stickney Surgery - Boston Sutterton Surgery - Boston Sutton Bridge Health Centre- Spalding Swineshead Surgery - Boston Swingbridge Surgery - Grantham Tasburgh Lodge Surgery - Woodhall Spa The Bassingham Surgery - Lincoln The Deepings Practice - Market Deeping The Glebe Practice - Saxilby The Glinton Surgery The Harrowby Lane Surgery - Grantham The Heath Surgery - Bracebridge Heath The Ingham Surgery The James Street Family Practice - Louth The New Coningsby Surgery The New Springwells Practice - Billingborough The North Thoresby Practice - Holton-le-Clay The Sidings Medical Practice - Boston The Stackyard Surgery - Grantham The University of Lincoln Health Service- Lincoln The Welby Practice - Bottesford The Welby Practice - Harlaxton The Welby Practice - Waltham The Wolds Branch - East Lindsey The Woodland Medical Practice - Lincoln The Wragby Surgery - Wragby Trent Valley Surgery - Lincoln Vine Street Surgery - Grantham Washingborough Family Practice - Branston Washingborough Surgery Welton Family Health Centre Willingham-By-Stow Surgery Woodhall Spa New Surgery Woodhall Spa New Surgery - Bardney Branch Other, GP not listed
If other, please specify name and address of GP Surgery
Education
Which School or Education Setting does the Child/Young Person attend?
* Required
Staff that support them in their education setting
Is there consent given for us to contact the school/college if needed?
** None Yes No
Other Services/Professionals involved
Is there anyone else helping the Child/Young Person with their emotional wellbeing at the moment? e.g. Social Work, Early Help team, Counsellor
Name of organisation/individual
Contact details
Is there consent given for us to contact this person/organisation?
** None Yes No
