This form will be sent to the North and East Dorset team.

Parent/Carer Referral

Required
Required
Required
Gender at birth Required
What is your child's address? Required
Required
Required
Is this referral being made so your child can attend a group in school run by the mental health support team? Your child's school will have spoken to you about this Required
Required
Is your child a young carer? Required
Required
Name and address of GP practice
Required
Required
If yes, please tell us which way the child would prefer us to communicate with them. You may choose more than one.
Do you have access to IT/technological equipment in the home setting to allow you to access online support from the MHST? (if required)

Family information

Required
Required
Required
Postal address (if different from child)

Reasons for referral

Required
Have any other agencies or professionals been involved with your child? Please tick all appropriate:
Does the young person currently express or show any self-harming behaviours/have a history of self-harming behaviours?
Does your child currently express any suicidal thoughts? Required

Consent

Please be aware that MHST is a school-based service and as such will discuss referrals with your child`s school

Required
Required

As part of the MHST service development, staff may be receiving training to be able to offer appropriate interventions to young people. As part of this training, they will need to submit recordings of assessment and intervention sessions.

For young people aged 13+: Does the young person consent to sessions being recorded for training, assessment and quality assurance?

The trust takes protecting your data very seriously. Contact details with will be kept securely on our system. We do not offer an emergency or urgent response via email. All personal data will be processed and stored by Dorset Healthcare University NHS foundation Trust in accordance with the Data Protection Act 2018 which incorporates the (EU) General Data Protection Regulation.

Privacy policy Required