Parent/Carer online referral form

Just so you know 

If you believe your child's life, or the life of another child or young person is at immediate risk, or you require immediate medical attention, please call 999 straight away or attend the nearest Accident & Emergency department.

To make a referral for your child or young person, you must have their consent if they are aged 13 years or over (this consent must be gained prior to making a referral via the Here4You line or completing this online form).

If your child is 13 years or over and doesn't consent to a referral you can contact our Here4You line for advice on 0800 234 6342.

The Here4You line is available 24 hours a day, however to make a referral please call the line between the hours of 9am and 4.45pm Monday to Friday (excluding public bank holidays).

Please complete this form in full. It’s important the information is correct so we can process the referral.


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 to set your choices.

I confirm I have read and agree to the above Confidentiality Disclaimer Required
I confirm I have parental responsibility for this child/young person Required

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

About You (the person completing the form)


We require a method of contact, by completing the field(s) below you are consenting to us contacting you in this way.

Do you require an interpreter?
Postal Address (if different from child/young person)

About the Child/Young Person

Their date of birth (dd/mm/yyyy) Required

Reason for Referral


Getting to know this child/young person further

Do they require an interpreter?
Does this child/young person have any diagnosed long term medical conditions or disabilities?

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...





Other Services/Professionals involved