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 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
Their Current Home Address (Required)
* Required
Child/Young Person’s Contact Information
If this child/young person is aged 13 years or over do they agree for us to contact them by...
Mobile
Email
Their Mobile Number
Their Email Address
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
About You (the person completing the form)
Your First Name
* Required
Your Surname
* Required
Relationship to Child/Young Person
We require a method of contact, by completing the field(s) below you are consenting to us contacting you in this way.
Your Mobile/Telephone Number (You give consent for us to contact you using these details)
Your 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
Yes
No
Reason for Referral
Which of the following best describes your child's current difficulties?
* Required
A Traumatic Experience or Experiences
Low Mood
Low Self-esteem
Managing their Emotions (Emotional Regulation)
Obsessions or Compulsions
Worries or Anxiety
Please provide more details regarding the selection you have made above.
* 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 current thoughts around harming themselves or others? If so, what is the nature of these thoughts.
* Required
Are you are aware of any previous thoughts or actions relating to harming themselves or others? If so, please give details and approximate dates.
* 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, 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:
Healthcare
GP Surgery of Child/Young Person
* Required** None Abbey Medical Practice Abbeyview Surgery Beacon Medical Practice Beechfield Medical Centre Billinghay Medical Practice Binbrook Surgery Birchwood Medical Practice Boultham Park Medical Practice Bourne Galletly Practice Team Branston & Heighington Family Practice Brant Road & Springcliffe Surgery Brayford Medical Practice Caistor Health Centre | The Health Centre Caskgate Street Surgery Caythorpe & Ancaster Surgery (Caythorpe) Cherry Willingham Church Walk Surgery Cleveland Surgery Cliff House Medical Practice Colsterworth Surgery | The Surgery Corringham Deepings Practice East Lindsey Medical Group: Newmarket Branch East Lindsey Medical Group: The Wolds Branch Glebe Park Surgery Gosberton Medical Centre Gresham Street Greyfriars Surgery Hawthorn Medical Practice Heart of Lincoln Medical Group Hereward Medical Centre Hibaldstow Medical Practice Holbeach Medical Centre Horncastle Medical Group James Street Family Practice Kirton Medical Centre Lakeside Healthcare Stamford Lindum Medical Practice Liquorpond Surgery Littlebury Medical Centre Long Sutton Medical Centre Marisco Medical Practice Market Cross Surgery Market Rasen Surgery Marsh Medical Practice Marton Merton Lodge Surgery Millview Medical Centre Minster Medical Practice Moulton Medical Centre Munro Medical Centre Navenby Cliff Villages Surgery Nettleham Medical Practice New Coningsby Surgery Newark Road Surgery Newland Health Centre North Thoresby Surgery Old Leake Medical Centre | The Medical Centre Other Parkside Medical Centre Richmond Medical Centre Ruskington Surgery Sidings Medical Practice Sleaford Medical Group Spilsby Surgery St Johns Medical Centre St Peters Hill Surgery Stickney Surgery | The Surgery Sutterton Surgery | The Surgery Swineshead Medical Group Swingbridge Surgery Tasburgh Lodge Surgery The Bassingham Surgery The Glebe Practice The Glenside Country Practice The Harrowby Lane Practice The Heath Surgery The Ingham Surgery The New Springwells Practice The Surgery Long Bennington The Welby Practice The Woodland Medical Practice Trent Valley Surgery University Health Centre Vine Street Surgery | Vine House Surgery Washingborough Surgery Welton Family Health Centre Willingham-By-Stow Surgery Woodhall Spa New Surgery Wragby Surgery
If other, please specify name and address of GP Surgery
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?
Yes
No
