BNSSG SilverCloud referral form

BNSSG referral for SilverCloud digital therapy for children and young people
SilverCloud programmes provide online guided self-help, a digital form of mental health support recommended by NICE (the National Institute for Health and Care Excellence). It's suitable for young people aged 13+ or for parents/carers of children aged 5 and above.

You may be:
* A young person - requesting support for yourself (or a parent/carer)
* A parent/carer - requesting support for yourself or your child
* A professional - referring a young person or a parent/carer

Please note that SilverCloud support is not suitable for young people where there are significant risk concerns.

If you're not sure, please call us on 0113 868 3483, or email us at bnssg@northpoint.org.uk

Otherwise please complete this form as best you can, using 'n/a' or 'don't know' if need be. You can also save and come back to it.

Date of Completion

DayMonthYear
About you
Please answer these first questions in relation to yourself, even if you're referring someone else for SilverCloud support.
Are you (yourself):*

A young person (13+)A parent/carerA professional
Your name*

First nameLast name
Your email address
(Optional - for a copy of this form, or if you might need an emailed link to Save and continue)
Referrer details
Referrer name*
Role or relationship to the young person or parent/carer you're referring*
Email address *
(A copy of your referral form will be sent here)
Contact number*
Name of young person or parent/carer

Who you're referring for SilverCloud support
SilverCloud programme user name*

First nameLast name

CYP details

[= true content of this section, with variant headings, CYP name fields and blurb, for different referral pathways]
CYP name [regardless of whether they are programme user or not]

First NameLast Name
Your details
Details of yourself & your child/young person
Details of the young person
Details of the parent/carer & child/young person
Name of SilverCloud programme user*

First nameLast name
Please answer the rest of the questions in this section in relation to yourself, even if this SilverCloud programme request is for your parent or carer.
Your name (young person)*

First nameLast name
Please answer the rest of the questions in this section in relation to your child, even if this SilverCloud programme request is for yourself.
Your child or young person's name*

First name of your childLast name of your child
Please answer the rest of the questions in this section in relation to the relevant child or young person, even if this SilverCloud programme request is for their parent/carer.
Child or young person's name*

First name of this parent/carer's childLast name of this parent/carer's child
Gender*
Date of birth*

DayMonthYear
Home address*
Home postcode*
School/college*
(If applicable; else please say if e.g. home-educated)
School/college postcode*
(If applicable, as for School/college)
School year group*
(If applicable, as for School/college)
GP practice*
TIP - Enter 1st letter of the practice name to shortcut the A-Z list
Other GP practice, if not found in A-Z list*
Ethnicity*
Contact details to access SilverCloud

We'll need an email address to send the user an invite for first-time access to SilverCloud - this can be a parent/carer's email address if preferred.
Email address for SilverCloud user*
Mobile number for SilverCloud user*
(Please double-check for accuracy - we'll only use this as a backup contact if need be)