MHST request for support School referral - Weymouth, Portland and West Dorset :: Dorset HealthCare University NHS Foundation Trust

If the young person is aged 13+, there may be times that we need to make contact via email or Text SMS. If they are happy to be contacted this way, please complete below.

Mobile number of child/young person (not applicable for under 13s)

Email address of child/young person (not applicable for under 13s)

Does the young person have access to IT/Technological equipment in the home setting to allow them to access online support from the MHST?

Name(s) of parent(s)/carer(s) and main parent/carer's contact details Required

Email address of parent/carer Required

Telephone number/mobile of parent/carer Required

If known and applicable please give the name of any other parent/carer who the child has contact with

If known and applicable please give the email address of any other parent/carer who the child has contact with

If known and applicable please give the contact number of any other parent/carer who the child has contact with

Name(s) of sibling(s) and dates of births

Reasons for referral

Please tell us briefly what your current concerns or worries are regarding the young person, and how long these have been present for Required

Has the young person had access to any specific support/interventions within school? Required

If yes, please supply details

Please give details of any treatment received and when:

Has there been any significant life changes recently? e.g. parental separation, bereavement, school change? Required

Does the young person have a history of emotional health difficulties?

Does the young person currently express or show any self harming behaviours/have a history of self harming behaviours? Required

If yes, please give details of these behaviours, date of last episode, frequency and any treatment required

If yes, please give details of type, frequency and duration and the current safety plan

What support or help do you think the child/young person or their family would benefit from? Required

Name of person Required

Role within the school of person completing this form Required

Email address of person making the referral Required

Telephone number of person making the referral Required

Has the referral been discussed during a school/college consultation meeting and agreed? Required

Is the child/young person aware of this referral? Please note that we cannot accept a referral if the child/young person does not consent to the referral Required

Is the parent/carer aware of this referral? If no, please give reasons why Required

The trust takes protecting data very seriously. Contact details given in this referral 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 If you are happy with the information you have completed, please press submit:

MHST request for support School referral - Weymouth, Portland and West Dorset

This form will be sent to the Weymouth, Portland and West Dorset team.

Child/young persons information

Family information

Reasons for referral

Referrer details

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