Parent/Carer Referral Form

Referral Information / Criteria

As a parent/carer wishing to access our support, please check that you meet all of the criteria listed below:

Your Young Person (YP) is aged between 13–17 years old

You and your YP are associated with Kent, attend education in Kent or are registered with a Kent GP (this includes Medway, for 18-25 year olds only)

You feel able and willing to work within a small group setting

Appropriate for early intervention (i.e not presenting with immediate risk)

Not taken any steps to end life within the past month. Note: we cannot accept people who have had suicidal intent or attempts in this time frame.

You consent to this referral

I understand that the information I share in this referral is confidential unless there could be immediate/serious risk to life. In which case, this information may need to be shared

Where did you hear about Mind and Body: Parent Programme?

Has your YP had any involvement with Mind and Body?

If you answered 'Yes' to the above, please add details of your young person here:

What is your relationship to the young person?

YP First name:

YP Last name:

YP Date of birth:

Referrer Information

Are you a...

Referrer Details (Professional Use Only)

Referrer name

Referrer contact number

Referrer email address

Secure email address

Agency (If CYMHS, please note the specific pathway, crisis team or if the referral is coming from SPA)

If currently involved, please tell us about what this intervention is/what the support looks like

Referrer full address

Please include postcode

Signposting

Where have you been signposted from

As you have selected "Other", please specify where

eg, website, Google, CYPMHS, GP, MAB Community Link Worker

Parent/Carer Details

First name

Last name

Preferred name

Pronouns

Date of birth

Ethnicity

Religion

Religion - Other

Gender

Gender - Other

Sexual orientation

Sexual orientation - Other

Accessibility Additional Needs

So that we can ensure that we meet any needs you may have, please complete the information below, where applicable:

Any additional needs or disabilities?

(Yes - Details)

Do you have any accessibility requirements to attend your appointment (whether virtual or face to face) If so, what are they?

(Yes - Details)

Are there any medical conditions or allergies that you would like to share with us or are relevant to share, including any medication?

(Yes - Details)

Further Information

Occupation

As you have selected "Other", please specify

GP Name:

GP Address:

GP Phone Number:

Do you receive any support from another organisation either for yourself or your family?

If so, please provide additional information:

Contact Details

Contact number

Are we able to leave an answer phone message:

Email address

Address

Street

Street 2

City

Post Code

Are we able to send letters to this address?

Emergency Contact Details

Name:

Relationship to you:

Contact Number (s):

Reasons for Referral

What do you hope to gain from this referral?

What are your current concerns?

What is going well for you right now and what support do you have?

Support Preferences

Which type of support would you prefer:

Type of support preferred

What are your preferred days for sessions:

What are your preferred times for sessions:

Between 9am and 11amBetween 12pm and 3pmBetween 3pm and 5pm

(N.B. If you are unable to access support at ANY of the times stated above, please leave blank.
We may not always be able to accommodate your requests but will try our best)