Referral forms for professionals

Referrer details
Is the health visitor aware of the referral? *
Client details
Partner/other significant adult details
Do they support with care of the children? *
Low mood/depression *
Child/children/other adult living in the home details
Referral criteria
Mild/moderate anxiety *
Mood Assessment must be completed
EDPS score (13+) *
GAD7 score (5+) *
PHQ9 score (10+) *
Any other significant information:
Name and contact details of other professionals working with the family
Are other professionals aware of this referral? *
Consent to share
Please gain verbal consent from the client that they are willing for their name and email address to be shared with other parents at each session and for Dorset HealthCare to send texts to their mobile phone and course information and resources via email.
Has the parent given verbal consent to share this information? *
The group facilitator may share information provided on this form, or that arises in the group, with other professionals who are working with you, to ensure you receive the most effective care.
Has the parent given verbal consent to share this information? *
Please remember anything discussed in the group remains in the group, unless there is a potential safeguarding issue.
ParenTalk virtual peer support group