The WISH Centre Referral Form - Harrow

Referrer Details


Safe2Speak - therapy for young people of all genders age 10-18 who self harm or have experienced domestic or sexual abuse or neglect
Self Harm Peer Support Group - weekly group for young women and female to male transgender youth ages 13-18 who self harm
CSE Support - Outreach or therapy for young people age 13-18 years (Harrow High Schools)
XGXP - online peer support group and monthly meetings for young women and female to male transgender young people age 16-25

Young Person Details

Young Person Disability

Young Person Additional Contact Details


Yes    No

Yes    No

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


Government training
Part-time work
Full-time work
Long term Sick/Disabled
Asylum seeker

GP Name and Surgery

Family Composition


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

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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