CALDERDALE MENTAL HEALTH SUPPORT TEAM REQUEST FOR SUPPORT FORM

Please fill in this form to help us understand why you are making a referral. We will contact you to arrange your session and may ask you further questions about your answers.

If you need urgent help ...
Please contact one or more of these people/services to find support:

Your pastoral lead/Head of Year, trusted adult in school
Your parent/carer
West Yorkshire Mental Health Helpline can be accessed by calling NHS 111
Your GP
Night Owls support line for children, young people, parents and carers on 0800 148 8244
Samaritans on 116 123

You can also find more crisis information here.

Confidentiality:

We won’t routinely share information about this referral with your parents/carers, unless you want us to. We will talk to you about your wishes when we speak to you.

If we are worried about your safety, we may need to speak to your parent / carer / school / GP to make sure that you are safe. We will try to speak to you first wherever this is possible.

Name*

First NameLast Name

Date of birth*

Address*

Street Address

Street Address Line 2

CityCounty

Post Code

School*

Your Email Address*

example@example.com

Your Phone Number*

Please enter a valid phone number.

Have you spoken to a member of staff in school about this issue, if so, who?*

YesNo

If yes, who?*

Are your parents/carers aware you are making a referral?*

YesNo

Please confirm you understand that you are referring for single session therapy (one session) therapy?*

YesNo

Single Session Therapy is for mild to moderate mental health presentations. If you have current thoughts of hurting yourself or others, please tell us and we can help you find the right support.*

Yes I doNo I don't

To process your referral, we may need to talk to other organisations who may be able to support you and your family, such as school, GP or school nursing. Do you consent to us sharing information with, and/or requesting information from, other relevant organisations?*

YesNo

Please be as specific as possible in your answers.

In one or two sentences, tell us about the main issue you want to talk about? *

How does this affect your life now?
How long has this been happening?
What do you think might be the impact, if it doesn’t get better?

Significance:*

What is the specific goal or goals you would like to achieve by the end of the session that would help you see that you have begun to make progress on the issue/or problem solved it in the session?*

What steps, successful or unsuccessful have you taken so far in dealing with the issue?*

For example, have you dealt with something similar before? If you struggle with answering this question, think of people who really know you and who are on your side, what would they say. *

Please name them and say what help each person can provide. *

What help do you hope I can best provide you in the session? Please tick the main one.*

Help me to develop my understandingHelp me by listening while I talk about the issueHelp me to explore how I feel about the issueHelp me to problem solve / get unstuckHelp me to make a decisionHelp me by signposting me to the most appropriate service for my situationOther (please specify)

CALDERDALE MENTAL HEALTH SUPPORT TEAM REQUEST FOR SUPPORT FORM

FOR COMPLETION FOLLOWING AGREEMENT IN MHST SUITABILITY DISCUSSION

REASON FOR SUPPORT REQUEST (from suitability discussion):

SAFEGUARDING

OTHER SUPPORT

MHST SUPPORT SUGGESTED IN SUITABILITY DISCUSSION

YOUNG PERSON

PARENT/CARERS

INCLUSION INFORMATION

CONSENT

Young Person Referral - Single Session Therapy

Why is this issue significant?

What is your goal in discussing this issue in the session?

How have you tried to deal with the issue up to this point?

What are the strengths or inner resources you have, that you could draw upon while tackling the issue?

Who are the people in your life who can support you as you tackle the issue?