CALDERDALE MENTAL HEALTH SUPPORT TEAM REQUEST FOR SUPPORT FORM

  • CALDERDALE MENTAL HEALTH SUPPORT TEAM REQUEST FOR SUPPORT FORM

  • After submitting this form, you'll receive an auto-response email with a copy of your Request for Support.

  • Are you a...*

  • FOR COMPLETION FOLLOWING AGREEMENT IN MHST SUITABILITY DISCUSSION

    guidance is available from the MHST – please ask if unsure
  • Date of Completion*
     - -

  • REASON FOR SUPPORT REQUEST (from suitability discussion):

  • SAFEGUARDING

  • Has the young person ever been Deemed a Child In Need?*
  • Has the young person ever been subject to a Child Protection Plan?*
  • Has the young person / family ever had social work involvement?*

  • OTHER SUPPORT

  • Current serious risk of harm to self?*

  • MHST SUPPORT SUGGESTED IN SUITABILITY DISCUSSION

    If known - May be more than one support type. Please be specific and use MHST staff guidance (phrases can be copied and pasted)

  • YOUNG PERSON

  • Date of birth*
     - -

  • PARENT/CARERS

  • INCLUSION INFORMATION

  • Child Looked After*
  • SEN Support*
  • EHCP*
  • Impact of flooding on mental health*
  • Risk of Exclusion*
  • Disability*

  • CONSENT

  • Young Person Referral - Single Session Therapy

    Mental Health Support Team (MHST)

  • 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.

  • Date of birth*
     - -
  • Format: 00000000000.
  • Have you spoken to a member of staff in school about this issue, if so, who?*
  • Are your parents/carers aware you are making a referral?*
  • Please confirm you understand that you are referring for single session therapy (one session) therapy?*
  • 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.*
  • 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?*

  • Please be as specific as possible in your answers.

  • Why is this issue significant? 

    • 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?

  • 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?  

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

  • Please press the submit button below

  • *
  • Should be Empty: