Online self-referral

Just so you know

If you believe your 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 you could go to the nearest Accident & Emergency department.

If it is not life threatening, but you feel you need immediate help you could call 111 who will be able to advise you about what to do. Alternatively, you could contact your family doctor (GP), teacher or parent/carer who will be able to help you to seek support.

Support and advice are also available from Childline call 0800 1111 or Samaritans call 116 123.

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

People aged 16 or over can also access support from adult services. If you would prefer to do so, please visit NHS Talking Therapies to complete a self referral.

If you are a parent/carer wishing to self-refer your child please contact our Here4You Line on call 0800 234 6342.

Young Person Self-Referral Form

Confidentiality Disclaimer

We will ask personal information to help us to deliver the best possible care. Everyone working for the NHS has a legal duty to maintain confidentiality.
All information will be kept in a ‘healthcare record’ on the trust’s computer system. Occasionally we may also use paper records. We’ll do everything we can to keep information you share safe.
Sometimes we need to talk to staff from other agencies (e.g. school, GP, social workers.) Anyone who received any information from us also has a legal duty to keep this confidential.
We will not share information without your prior agreement or knowledge unless the health and safety of yourself or others is at risk or if we are required by law under the Data Protection Act 2018.
You have a right to see and comment on any of the information we hold about you. If you 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 framework for processing your information is detailed on our Trust website privacy policy and ‘How we use and share your information to help you’ leaflet.
If you do not wish to have your records accessed for research purposes, please visit https://digital.nhs.uk/services/national-data-opt-out-programme to set your choices.

I understand that this referral will be looked at by the Access Team, and I will be kept informed of what happens next.

I confirm I have read and agree to the above Confidentiality Disclaimer. Required

Yes

About You

Self-referral is currently only open to young people aged 13 and over. If you would rather speak to us on the phone, call our Here4You line where a practitioner can support you to make the referral.

I am a young person aged 13+ making this referral about myself Required

Yes

First Name Required

Surname Required

Preferred name, if this is not your legal name

My pronouns are...

Date of birth (dd/mm/yyyy) Required

Reason for Referral

Please describe what difficulties you are experiencing in relation to your emotional wellbeing and/or mental health? Required

How is this impacting on your day to day life including how long you've been feeling this way? ( Please consider family, school work, friends, sleep) Required

What else do you think we should know? (recent or past events that may have contributed to how you're feeling, any thoughts around harming yourself, things that are going well) Required

Getting to know you further

What is your sex assigned at birth? Required

Which of the following most accurately describe(s) you?

If other, please specify

First language

Do you require an interpreter?

Yes

Contact Information

Current Home Address (required)

Address 1

Address 2

City

State/Province

Country

Postal Code

I give consent for you to send mail to this address

Preferred contact number (if we need to contact you, this is the number we will use) Required

I give consent for you to leave a voicemail message on this number Required

Email Address (We will use this to confirm we have received this form)

I give consent for you to contact me on this Email Address

Parent/Carer details

Please identify the person who cares for you most of the time, for example the person you live with.

My Parent/Carer knows about this referral Required

I give consent for you to contact my Parent/Carer Required

Name of Parent/Carer

Relationship to you

Are you a child in care?

Phone number of parent/carer

Healthcare

GP Surgery Required

If other, please specify name and address of GP Surgery

Education

Do you give consent for us to contact your school/college if needed?

Which School/ College do you attend? Required

Staff that support me in my education setting

Other Services/Professionals involved

Is there anyone else helping you with your emotional wellbeing at the moment? e.g. Social Work, Early Help team, Counsellor Required

I give consent for you to contact this person/organisation

Name of organisation/individual

Contact details

I agree to the privacy policy.

Online self-referral

Just so you know

Young Person Self-Referral Form

About You

Reason for Referral

Getting to know you further

Contact Information

Parent/Carer details

Healthcare

Education

Other Services/Professionals involved

Trust Headquarters

Useful Links

Online self-referral

Just so you know

Young Person Self-Referral Form

Form

About You

Reason for Referral

Getting to know you further

Contact Information

Parent/Carer details

Healthcare

Education

Other Services/Professionals involved

Trust Headquarters

Useful Links

Accessibility tools