MHST request for support young person self-referral - North and East Dorset :: Dorset HealthCare University NHS Foundation Trust

Future correspondence may be sent via email. Please ensure you check junk/spam mail.

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

Name of school Required

Please be aware that MHST is a school-based service and as such will need to discuss referrals with your school. If there is a preferred contact name please provide it:

If yes, please give details

Are you a young carer? If yes, please give details of your caring responsibilities

Is an interpreter required when we talk to you or meet you?

If you have chosen more than one, please specify which you favour

Names of your parent(s)/carer(s) Required

If you are under 16 years old - MHST will need consent from your parent/carer

Telephone number of main parent/carer Required

Email address of main parent/carer Required

Siblings names and dates of birth

Reasons for referral

What are your worries about your mental health and emotional wellbeing? Required

When did you start to feel this way?

How is it affecting your life?

Has anything changed for you recently? For example, parents separating, someone you love dying, school change Required

We ask about self harm and harmful behaviours as it helps us better understand what support you may need. We understand that this may be difficult to tell us about

If yes, When was the last? What did you do? How often? Have you told anybody? If so, who?

We ask about suicidal thoughts to help you keep you safe, any disclosures will be shared with school and parent/carers.

Could you tell us about these thoughts? Have you ever acted on these thoughts? Have you told anyone? If yes, who? Do you have a plan to keep yourself safe?

What do you think would be helpful around your health and emotional wellbeing?

Thank you for completing this form and taking the first step to getting some support.

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.

The trust takes protecting your data very seriously. Contact details of both the referrer and the young person the referral corresponds with will be kept securely on our system. We do not offer an emergency or urgent response via email.

If you would like a copy of the referral form, please add your email address in the box below.

MHST request for support young person self-referral - North and East Dorset

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

Your information

Family information

Reasons for referral

We ask about self harm and harmful behaviours as it helps us better understand what support you may need. We understand that this may be difficult to tell us about

We ask about suicidal thoughts to help you keep you safe, any disclosures will be shared with school and parent/carers.

Thank you for completing this form and taking the first step to getting some support.

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