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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

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
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Reason for Referral

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Getting to know you further

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Do you require an interpreter?

Contact Information

Current Home Address (required) Required
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Parent/Carer details

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

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Healthcare

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Education

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Other Services/Professionals involved

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