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.
FOR COMPLETION FOLLOWING AGREEMENT IN MHST SUITABILITY DISCUSSION

guidance is available from the MHST – please ask if unsure
Name of School Staff member providing information*
Email of School Staff member providing information*
example@example.com
Name of School*
Name of MHST staff member involved in suitability discussion:*
Date of Completion*

DayMonthYear
REASON FOR SUPPORT REQUEST (from suitability discussion):
Mental health support needs & concerns: e.g. anxiety, mood, exam stress. Known history inc previous support, assessments and what is working. What the YP would like to change.*
Professional’s voice (names)
Child/ Young Person Voice (If available. With consent)
Parent/Carers Voice (If available. With consent)
SAFEGUARDING
Has the young person ever been Deemed a Child In Need?*

Yes CurrentlyYes PreviouslyNeverNot Known
Has the young person ever been subject to a Child Protection Plan?*

Yes CurrentlyYes PreviouslyNeverNot Known
Has the young person / family ever had social work involvement?*

Yes CurrentlyYes PreviouslyNeverNot Known
Provide further detail i.e. reason for involvement, dates of involvement, name and contact details of any current social worker*
Provide further detail of any other safeguarding concerns if relevant
OTHER SUPPORT
Please provide details of other services involved with YP/family
Current serious risk of harm to self?*

YesNo
Please provide further details*
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)
Function 1: Direct Support with EMHP/MHST Practitioner inc Silvercloud (YP or parent), Consultation, or Single Session Therapy
Function 2: Whole School Work
Function 3: Advice/ Liaison/ supported onward referral
YOUNG PERSON
Name*
Gender*
Date of birth*

DayMonthYear
Year Group*
Ethnicity*
Address*
GP Surgery*
YP email (for S/C if relevant)
YP mobile number (if relevant)
PARENT/CARERS
Parent Carer 1 Name*
Parent Carer 1 Relationship to YP*
Parent Carer 1 Email
Parent Carer 1 Mobile number*
Parent Carer 2 Name
if relevant
Parent Carer 2 Relationship to YP
Parent Carer 2 Email
Parent Carer 2 Mobile number
INCLUSION INFORMATION
Child Looked After*

YesNo
SEN Support*

YesNo
EHCP*

YesNo
Impact of flooding on mental health*

YesNo
Risk of Exclusion*

YesNo
Disability*

YesNo
Disability details*
CONSENT
Tick to confirm that parent/carer(s) have given consent for this Request For Support to be shared*

Tick
Early HelpChild in NeedChild Protection PlanSocial WorkerNo safeguarding concerns
Should be Empty:

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