SilverCloud digital therapy referral for young people 16-19

  • SilverCloud digital therapy referral for young people 16-19

  • 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).

    This SilverCloud referral pathway is for young people aged 16-19 only, and/or their parent/carers.

    ** For young people under 16 or over 19, please see the information at the end of this section. **

    Otherwise, please complete this form. You may be:

    • A young person - requesting support for yourself and/or your parent/carer
    • A parent/carer - requesting support for your young person and/or yourself
    • A professional - referring a young person and/or their parent/carer

    Please note that SilverCloud support is not suitable where there are significant risk concerns around the young person.

    If you're not sure, please:

    • Email us at silvercloud16-19@northpoint.org.uk
    • Or call us on 01422 300001 if you're in the Calderdale area ...
      ... or 0113 868 5676 if you're in the Leeds area

    You can also save this form and come back to it.

    ____________________


    ** For a young person under 16 (and/or their parent/carers), please talk to a member of staff in school about alternative support. These web pages may also be helpful:

    • Open Minds in Calderdale
    • MindMate - Leeds

    ** For a young person over 19, these web pages may be helpful in finding alternative support:

    • Open Minds in Calderdale
    • VitaHealth - Calderdale Talking Therapies
    • MindMate - Leeds
    • Leeds Mental Wellbeing Service (LMWS)
  • I am ...*
  • I am requesting support for ... (tick all that apply)*
  • Submission date
     / /

  • Your contact details

  • Young person's details

  • Please complete all requested details in the form for your young person, even if you're only referring yourself - as this SilverCloud support is still provided indirectly for the young person, so the details will be held under their name.

  • Please complete all requested details in the form for the young person, even if you're only referring their parent/carer - as this SilverCloud support is still provided indirectly for the young person, so the details will be held under their name.

  • Format: 07000 000000.
  • Living in ...*

  • Referrer contact details

  • Find the right SilverCloud support

  • Please choose from the SilverCloud programmes shown below.

    If you're not sure:

    • Email us at silvercloud16-19@northpoint.org.uk
    • Or call us on 01422 300001 if you're in the Calderdale area ...
    • ... or 0113 868 5676 if you're in the Leeds area

    Living well ... courses - Please note that these are open to all young people who would find the content helpful, with or without a diagnosis.

  • Programmes for young people 16-19 - choose one of the following options*
  • Programmes for parent/carers - choose one of the following options*

  • Consent

  • More about you

  • More about the young person

  • Please complete all requested details in the form for yourself, even if you're only referring your parent/carer - as this SilverCloud support is still provided indirectly for you, so the details will be held under your name.

  • Date of birth*
     / /
  • DoB [HIDDEN for age calculation]*
     / /
  • Today [HIDDEN for age calculation]*
     / /

  • This SilverCloud pathway is for young people aged 16-19 only (and/or their parent/carers), so unfortunately we can't offer this support because of the young person's age.

    Please talk to a member of staff in your school or college about alternative support.

    These web pages for under-16s may also be helpful:

    • Open Minds in Calderdale
    • MindMate - Leeds

     

  • This SilverCloud pathway is for young people aged 16-19 only (and/or their parent/carers), so unfortunately we can't offer this support because of the young person's age.

    These web pages for over-19s may be helpful in finding alternative support:

    • Open Minds in Calderdale
    • VitaHealth - Calderdale Talking Therapies
    • MindMate - Leeds
    • Leeds Mental Wellbeing Service (LMWS)

     

    • Section collapse - END FORM here if outside age range 

  • Additional information

  • Please answer these questions as best you can. The reason we're asking for this information is so that the SilverCloud Supporter is aware of anything important and can help you (and/or your parent/carer) in the best way possible.

  • Please answer these questions as best you can. The reason we're asking for this information is so that the SilverCloud Supporter is aware of anything important and can help the young person (and/or their parent/carer) in the best way possible.

  • Risk

  • Are you at risk of hurting yourself or others?*
  • Is there a current risk of harm to self or others?*

  • Inclusion

  • Are you living in foster care or local authority care? (either of these)*
  • Do you have special educational needs (SEN) support in school?*
  • Do you have an Education, Health and Care Plan (EHCP)?*
  • Do you have any disabilities or other support needs?*
  • Looked After Child?*
  • SEN support?*
  • EHCP?*
  • Disabilities or other relevant support needs?*

  • Safeguarding

  • Safeguarding - Please tick all that apply*

  • Other services involved

  • Parent/carer (or trusted adult) details

  • Please give details for at least one parent/carer (or trusted adult), with an email address and/or phone number. Complete/overwrite these details as appropriate, or put 'n/a' if not available/applicable.

  • Note - We would not make contact with them without your awareness, unless there are concerns of safeguarding or significant risk to yourself or others.

  • Format: 07000 000000.

  •  

    Thank you - please submit below

    You'll receive an autoresponder email with a copy of your submission.

     

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