SILVERCLOUD REGISTRATION PAGE

CALDERDALE OPEN MINDS REGISTRATION PAGE FOR SILVERCLOUD DIGITAL THERAPY

SilverCloud can be accessed by young people aged 14+ or by parents/carers of children aged 5/6 and above. The support is not suitable for young people with risk concerns. If unsure call us on 01422 300 001
Silvercloud Digital Therapy
REFERRER
Updated e-Referral form

Please note, in March 2026 we updated our online referral form. The existing eReferral forms have been combined into a single refreshed form.

If you have any questions, please do not hesitate to telephone the team on 01422 300 001.

To be redirected to the new form, press submit below.

Select "Emotional Wellbeing" and then "Get Support Online" from the support options.
Name of Referrer*
Role of Referrer or relationship to young person*
If self referral please indicate here
E-mail address of Referrer*
Contact Number of Referrer
SUPPORT REQUESTED
Parent / CarerYoung Person (aged 14+)
Space from AnxietySpace from Low MoodSpace from Low Mood & AnxietyLiving Well With ADHD (suitable for aged 15+)Living Well as an Autistic Teen
Supporting an Anxious Child or TeenSupporting a Child With ADHDSupporting an Autistic Child or Teen
REASON FOR SUPPORT REQUEST
Please summarise the reason for this request (e.g. anxiety, mood, exam stress, ADHD traits)*
Please summarise any known risk (e.g. suicidal thoughts, self harm), and any relevant support needs (e.g. autism or dyslexia)*
YesNo
Please provide further details*
ABOUT THE CHILD / YOUNG PERSON
Name*
Gender*
Date of birth*

DayMonthYear
Home Address*
Including Postcode
School*
School Postcode*
Year Group*
Ethnicity*
GP Surgery*
INCLUSION INFORMATION
YesNo
YesNo
YesNo
YesNo
Disability details*
SAFEGUARDING
Social WorkerEarly HelpChild Protection PlanNo safeguarding concerns
Provide further detail if relevant
OTHER SUPPORT
Please provide details of other services involved with YP/family
PARENT/CARER(S)
Parent Carer 1 Name*
Parent Carer 1 Relationship to YP*
Parent Carer 1 Mobile number*
Parent Carer 1 Email
Parent Carer 2 Name
if relevant
Parent Carer 2 Relationship to YP
Parent Carer 2 Mobile number
Parent Carer 2 Email
CONTACT DETAILS TO ACCESS SILVERCLOUD

We need to speak to the young person or parent/carer to explain the process, and we need an e-mail address to provide them with access to the programme
Parent / CarerYoung Person (aged 14+)
Email address*
Mobile number*
Tick
Date of Completion*

DayMonthYear
SilverCloud for Young Person (Space from Anxiety)
SilverCloud for Parent/Carer (Supporting Anxious Child/Teen)
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CALDERDALE OPEN MINDS REGISTRATION PAGE FOR SILVERCLOUD DIGITAL THERAPY

Silvercloud Digital Therapy

REFERRER

Updated e-Referral form

SUPPORT REQUESTED

REASON FOR SUPPORT REQUEST

ABOUT THE CHILD / YOUNG PERSON

INCLUSION INFORMATION

SAFEGUARDING

OTHER SUPPORT

PARENT/CARER(S)

CONTACT DETAILS TO ACCESS SILVERCLOUD