Parent referral formThis form will take 5-10 minutes to complete, please fill in this form if the child is under 18 years of age. If they are 18 or over, please help them to complete the self-referral form here. Name of the child * First Name Last Name Your relationship to this child Parent Foster parent Grandparent Guardian Gender Male Female Indeterminate Pronouns She/her He/him They/their/them Their date of birth * MM DD YYYY Their address Address 1 Address 2 City State/Province Zip/Postal Code Country Your Name * First Name Last Name Your phone number * (###) ### #### Your email * Are you their next of kin/emergency contact * Yes No Main reasons you are requesting support for them * tick all that apply Low moods/depression Anxiety Relationship struggles Anger Obsessions/compulsions Self harm Addiction (drugs, alcohol, gambling) Historic trauma Victim of a crime Physical health issues impacting mental health Grief School avoidance I have issues with food I just want to talk to someone Tell us a little bit about what has been happening * Have they seen their GP regarding their mental health? * Yes No Have they ever been referred to children's NHS mental health services (CAMHS) * Currently under the care of CAMHS or a school support alternative Yes previously but now discharged No Is their mental health affecting their education? * No Yes, they are missing some school They are missing school more often than not Their ethnicity White Mixed heritage Asian or Asian British Black or Black British Other ethnic groups Not known GP Practice * British Armed Forces * Are you or a member of your family a former or serving member of the British Armed Forces. No I am a serving member I am a veteran Family member who is serving or former member Do you have an issues with accesibilty that we may need to take into account for your appointments lease tick here if you want to discuss our financial hardship fund to further subsidise your sessions Yes please Thank you for taking the time to complete this referral. You will be contacted via email with information to arrange a pre-therapy appointment. Please check your junk mail for an email from admin@incharleysmemory.com. We try to respond to all referrals within 48 hours.
