CALDERDALE OPEN MINDS (CAMHS) 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
REFERRER
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
Programme to be accessed by...
Parent / Carer
Young Person (aged 14+)
Programmes for Young People (aged 14+)
*
Space from Anxiety
Space From Low Mood
Space from Low Mood & Anxiety
Living Well With ADHD (suitable for aged 15+)
Programmes for Parent / Carers
*
Supporting an Anxious Child
Supporting an Anxious Teen
Supporting a Child With ADHD
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)
*
Current serious risk of harm to self?
*
Yes
No
Please provide further details
*
ABOUT THE CHILD / YOUNG PERSON
Name
*
Gender
*
Date of birth
*
-
Day
-
Month
Year
Home Address
*
Including Postcode
School
*
School Postcode
*
Year Group
*
Ethnicity
*
GP Surgery
*
INCLUSION INFORMATION
Child Looked After
*
Yes
No
SEN Support
*
Yes
No
EHCP
*
Yes
No
Disability
*
Yes
No
Disability details
*
SAFEGUARDING
Tick as relevant
*
Social Worker
Early Help
Child Protection Plan
No 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
Contact details for
*
Parent / Carer
Young Person (aged 14+)
Email address
*
Mobile number
*
Tick to confirm that parent/carer(s) have given consent for this Request For Support to be shared
*
Tick
Save
Submit
Date of Completion
*
-
Day
-
Month
Year
SilverCloud for Young Person (Space from Anxiety)
SilverCloud for Parent/Carer (Supporting Anxious Child/Teen)
Should be Empty: