Refer Myself - The wïsh centre

Referrer

Heads Up

If you have come via heads up, please tick this box.

Referrer Details

Referral Date

Young Person

Young Person Details

Name *

Date of Birth *

Gender *

Religion

Gender - Other

Religion - Other

Contact Number *

Ethnicity *

Etnicity - Other

Email

Sexuality

Sexuality - Other

School / College / Job / Not Employed / Training: -Please state which *

Disability

If you think you have a disability tick the most appropriate. If you have multiple then choose the one that has the biggest impact.

Disability

Disability - Other

Additional

Young Person Additional Contact Details

House Name/No and Road *

Town/City *

Postcode *

Is it Ok to contact You directly? *

Yes

No

Is it Ok to leave a telephone message? *

Yes

No

Safe Emergency Contacts

(Must be over 18 and at least one to be in the current household.)

Safe Emergency contact no.1 Name/ phone *

For digital support, under 18s will need parental consent. Have your parent /carers been informed about the referral? *

Yes

No

Please state who is in the current household with you: *

Referral

Which programme are you referring yourself to?

(tick all that apply)

Outreach- up to four sessions to discuss my options

Therapy- 1:1 open ended therapy sessions

Peer Support – A weekly non-judgemental space to make friends and learn new coping mechanisms, facilitated by a staff member

Art Therapy Group

Please state reasons for referral

Are you taking any medication? *

Yes

No

Further details

Do you have a clinical diagnosis? *

Yes

No

Further details

Have you made any suicide attempts or been hospitalised? *

Yes

No

Further details

Do you have a recent history of violence or aggressive behaviour toward others? *

Yes

No

Further details

Have you been to A&E for Self Harm in the last 12 months? *

Yes

No

How many times?

Are there any associated risks e.g. Domestic/Honour-based violence? *

Yes

No

Further details

Are you a Class A drug user? *

Yes

No

Further details

Are you or any family members on a Child in Need plan? *

Yes

No

Further details

Are you or any family members on a Child Protection Plan *

Yes

No

Further details

Have you been a victim of sexual violence/exploitation? *

Yes

No

Further details

Intervention details

Please add details of the intervention(s):

Organisations or workers involved

Please name any other organisations or workers involved in the the clients welfare. E.g. social worker, CAMHS

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Referrer

Referrer Details

Young Person

Young Person Details

Disability

Additional

Young Person Additional Contact Details

Referral

Referral