Your name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Name of child / young person *

First Name

Last Name

Child / young person's date of birth *

MM

DD

YYYY

Significant events and experiences *

This child / young person

had a change of school placement (other than usual transitions)

has moved homes

is experiencing some instability at home (e.g. in relationships or environment)

has experienced discrimination, threatening behaviour or violence in their community

has moved country for asylum

has English as an additional language (EAL)

had lived / is living with someone that has been ill or unwell

has lived / is living with someone with significant mental health needs

is a young carer

has lost a parent through divorce, death or abandonment

has lived / is living with someone that has gone to prison

has been exposed to domestic violence or significant conflict in the home

has lived / is living with someone who has suffered with drug or alcohol abuse

has experienced abuse and/or neglect

has intentionally harmed themself or others

Been involved in or witnessed a serious accident / incident that seems to affect them

Something not mentioned here

None of the above

Support and services *

This child / young person

is known to children's social care

has had a child protection plan

is eligible for free school meals

has had medical needs plan

has received support for Special Educational Needs (SEN) at school

is known to allied health professions, e.g. speech and language or occupational health

has an Education, Health and Care Plan (EHCP)

has seen a psychological therapist before

is known to the child and adolescent mental health service (CAMHS)

None of the above

Something else not mentioned

What services are you interested in that I offer? *

Individual psychotherapy for a child / young person

Joint parent/child work or family work

Parent support

State of mind assessment

Professional consultation

Not sure

Please tick each corresponding box to indicate whether you give your consent/ Please note that services may be refused if consent is not given.

CONSENT TO HOLD DATA: I agree to PH Child Psychology & Psychotherapy Services holding information from this referral form and in a written log for the purposes of clinical practice and client care. The information I provide will be kept secure and confidential. The sharing of any information will be done strictly according to any ‘need to know’ basis (i.e. if the health or well-being of a client is at risk or to prevent a serious crime). I am aware that I can find more information from the Date Protection Policy using the link on this page.

CONSENT TO SHARE DATA: I agree for PH Child Psychology & Psychotherapy Services to contact and share information with other services (i.e. my child's educational setting and GP). I understand that should this need to happen it will be discussed and agreed with me first and I can withdraw my consent at any time in writing (e.g. via email to drhalcrow.psych@googlemail.com).

SAFEGUARDING: I understand that PH Child Psychology & Psychotherapy Services is responsible for ensuring every child, young person and family using their services is safe and protected from harm. This means that should they become concerned about the safety of my child or our family, they will aim to discuss this with me in the first instance. It may be necessary for them to share information in order to seek advice or make referrals to the Children’s Advice and Duty Service (CADS). I am aware that I can find more information from the Safeguarding Policy using the link on this page..