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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. If the information provided is inaccurate, we will be unable to 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.

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. 

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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.

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Reason for Referral

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Getting to know you further

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Contact Information

Current Home Address
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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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