Online self-referral

Please be aware

CYP Services include:

CAMHS (Child and Adolescent Mental Health Service)
HML (Healthy Minds Lincolnshire)
MHST (Mental Health Support Teams).

Our service hours are Monday to Friday 9am to 5pm.

The Here4You Access Team look at all referrals within 72 hours. These services do not offer urgent or emergency care.

People aged 16 or over can also access support from adult services. If you would prefer to do so, please visit the Step2Change website to complete a self referral.

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 Telephone 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 telephone 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 telephone 0800 1111 or Samaritans telephone 116 123.

Please complete this form in full. Please ensure any information provided is accurate and reflective of the details your GP holds. If the information provided is inaccurate, we will be unable to process the referral.

Young Person Self-Referral Form

Confidentiality Disclaimer

During your contact with Lincolnshire Partnership NHS Foundation Trust you will be asked to provide personal information to help us to deliver the best possible care to you. Everyone working for the NHS has a legal duty to maintain the highest level of confidentiality about all patient information.

The information you provide 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 you have entrusted to us.

Sometimes other agencies are also involved in your care and we may need to share information with them in order to deliver your care. Anyone who receives confidential information about you from us is also under a legal duty of confidence. We will not disclose your information outside these agencies without your 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 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 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 online referral will be considered, and I will be notified of the outcome. If an assessment and/or intervention is agreed then, I understand that I will be informed of the date(s) when this work will take place.

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 are a parent/carer wishing to self-refer with your child’s consent or under 13 please contact our Here4You Line on 0800 2346 342.

I am a young person aged 13+ making this referral on my behalf Required

Yes

Title

If other, please specify below

First Name Required

Surname Required

Preferred name, if this is not your legal name

Date of birth (dd/mm/yyyy) Required

My pronouns are...

What is your sex assigned at birth? Required

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

Female

Intersex

Male

Non-binary

Transgender

Prefer not to answer

If other, please specify

What is your sexual orientation?

If other, please specify

Ethnicity

If other, please specify

Religion

If other, please specify

First language

Interpreter Required

Yes

Do you consider yourself to have a long-term medical condition or disability?

If yes, please provide details

Contact Information

Current Home Address

Address 1

Address 2

City

State/Province

Country

Postal Code

I give consent for you to send mail to this address

Preferred contact number (this is the number we will call you on to discuss your referral). Required

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

Alternative contact number (optional)

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

Email Address (optional)

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

Name of Parent/Carer

Relationship to you

Are you a child in care?

Phone number of parent/carer

I give consent for you to contact my parent/carer Required

Healthcare

GP Surgery Required

If other, please specify name and address of GP Surgery

Education

Which School or Education Setting do you attend? Required

Which village/ town/ city is your education setting in? Required

Staff that support me in my education setting

Do you give consent for us to contact this person?

Reason for Referral

Please let us know why you'd like to be seen by Children and Young People's Mental Health Services, including details of any previous or current mental health problems. The more information you include, the better we can decide on how best to help you.

Please describe what difficulties you are experiencing in relation to your mental health? (e.g. worries, self-harm, low mood, eating difficulties) Required

How long have you been feeling this way? Required

How is this impacting on your day to day? ( Please consider family, school work, friends, sleep) Required

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

What do you think you need support with? what would you like to be different? Required

Other Services/Professionals involved

Have you been open to any of our services within the past 6 months? (Healthy Minds Lincolnshire, CAMHS, Mental Health Support Team)

Are you currently involved with any other services or organisations? e.g. Social Work, Early Help team Required

Name of organisation/individual

Contact details

I give consent for you to contact this person/organisation

I agree to the privacy policy.

Online self-referral

Please be aware

Young Person Self-Referral Form

Confidentiality Disclaimer

About You

Contact Information

Parent/Carer details

Healthcare

Education

Reason for Referral

Other Services/Professionals involved

Trust Headquarters

Useful Links

Online self-referral

Please be aware

Young Person Self-Referral Form

Form

Confidentiality Disclaimer

About You

Contact Information

Parent/Carer details

Healthcare

Education

Reason for Referral

Other Services/Professionals involved

Trust Headquarters

Useful Links

Accessibility tools