The WISH Centre Referral Form - Harrow

Referrer Details

Programme

Safe2Speak Counselling for self harm, domestic violence, abuse or neglect
Girls Xpress Self harm Peer Support Group
Outreach The Outreach Programme

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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