The WISH Centre Referral Form - Camden

Referrer Details

Programme

Self Harm Peer Support Group - Weekly group for young women and female to male transgender youth ages 13-18 who self harm

Young Person Details

Young Person Disability

Young Person Additional Contact Details

Address:

Yes    No

Yes    No


Yes    No
Please be aware if the young person is under 14 disclosures may have to be made

Status

School
Government training
Part-time work
Unemployed
Refugee
College
Full-time work
Long term Sick/Disabled
Asylum seeker
Other

GP Name and Surgery

Family Composition

Name
Relationship
Action

Alone Partner Parents Carers In Care Relatives

Reason For Referral


Self Harm Sexual Exploitation Abuse

Anxiety/Stress Depression/Sadness Emotional Resilience Difficulties Lack of Positive Coping Mechanisms Trauma Suicidal Ideation Sexual Identity Other - Please provide info below

Clinical/Support History

Query
YES
NO
Is the young person/you taking any medication?
Does the young person/you have a clinical diagnosis?
Has the young person/you made any suicide attempts or been hospitalised?
Does the young person/you have a recent history of violence or aggressive behaviour toward others?
Has the young person/you been to A&E for Self Harm in the last 12 months?
If yes, How many times?
Are there any known associated risks e.g. Domestic/Honour-based violence?
Is the young person/you a Class A drug user?
Is the young person/you or family members on a Child in Need plan?
Is the young person/you or family members on a Child Protection plan?
Has the young person/you been a victim of sexual violence/exploitation?

Interventions already completed


GP A & E Housing Social Care Drug & Alcohol Forced Marriage Unit CAMHS Referral Mental Health Team Troubled Families



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