Mind & Body Referral Form
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lease select your
language
Referral Information
Please check that you meet
all
of the criteria listed below.
If all criteria are met, then please proceed with the referral and complete the form in as much detail as possible.
If you are a parent/carer completing this form then please complete it alongside your young person.
Criteria
All criteria must be met to be able to accept the referral. Please tick to confirm that the young person meets the following:
Aged 13 – 25 years old
Associated with Kent, attend education in Kent or are registered with a Kent GP (this includes Medway, for 18-25 year olds only)
Able and willing to work within a group setting
Involved in or potentially vulnerable to self harming behaviours
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
Consenting to this referral
Referrer Information
Are you a...
Please select...
Parent/Carer
Young Person (13-25)
Professional
Referrer Details
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
Please select...
CYPMHS / NELFT
GP
Early Help
CMHT / KMPT
School
Friend / family member
We Are With You Website
Other
As you have selected "Other", please specify where
eg, website, google, CYPMHS, GP, MAB Community Link Worker
Young Person's Details
First name
Last name
Preferred name
Pronouns
Date of birth
Ethnicity
Please select...
White British
White Irish
Any other White Background
White and Black Caribbean
White and Black African
White and Asian
Any Other Mixed Background
Asian/British Indian
Asian/British Pakistani
Asian/British Bangladeshi
Any Other Asian Background
Black/British Caribbean
Black/British African
Any Other Black Background
Chinese
Any Other Ethnic Background
Prefer Not To Say
Not Known
Religion
Please select...
Buddhist
Jewish
Sikh
Christian
Hindu
Muslim
No religion
Any other religion.
Prefer Not To Say
Religion - Other
Gender
Please select...
Female
Male
Transgender
Non-Binary
Prefer Not to Say
Other
Gender - Other
Sexual orientation
Please select...
Bi-sexual
Gay/lesbian
Heterosexual
Other
Pansexual
Prefer not to say
Sexual orientation - Other
Additional Needs
Any additional needs or disabilities?
Please select...
Behaviour and emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self-care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc.)
Sight
Speech
Autistic Spectrum Disorder
Other
No Disability
Not Stated
Hold the shift or command key and use your mouse to select more than one option
Other needs/disabilities
Do you have any accessibility requirements to attend your appointment (whether virtual or face to face)? If so, what are they?
Any medical conditions or allergies?
Please select...
Yes
No
Conditions/allergies - details
Are you taking any medication?
Please select...
Yes
No
Medication - details
Further Information
Occupation
Please select...
Student
Employed
NEET
Other
School year (if applicable)
Please select...
8
9
10
11
12
13
College
University
N/A
School contact details
GP contact details
Receives additional support from any other agency/organisation
Please select...
Yes
No
If yes, please tell us about this intervention/what the support looks like
If yes, please provide support contact information
Contact Details
Contact number
Email address
Can we leave an answer phone message
Please select...
Yes
No
Address
Street
Street 2
City
Post Code
Please enter a valid postcode entry, for example CT25 DT9 or KJ5 3ER.
Can letters be sent to this address
Please select...
Yes
No
Parent / Carer / Next of Kin Details
Parent/Carer/Next of Kin Name
Relationship to person being referred
Parent/Carer/Next of Kin Number
Parent/Carer/Next of Kin Email
Information on Support Preferences
Which type of support would you prefer:
(please note we will take this into account wherever possible but cannot guarantee which support will be offered)
Type of support preferred
Please select...
Face to face
Remote / virtual
Please note that for
over 18s
, all sessions are currently delivered virtually
Preferred area to attend sessions
Please select...
Ashford
Dover
Gravesham
Maidstone
Medway (18-25 year olds only)
Sittingbourne
Thanet
Whitstable
Reasons for Referral
What is the person seeking support currently struggling with? What are the main concerns?
How long has this been going on for and what are the triggers?
What does the person seeking support hope to gain from this referral and from taking part in Mind and Body?
Identified Risks
Please select the appropriate options and provide further details when prompted.
Self-harm
Within last month
One to six months
Six months or longer
None or unknown
Self-harm - please give further information including details of who is aware
Harm to others
Within last month
One to six months
Six months or longer
None or unknown
Harm to others - please give further information including details of who is aware
Suicidal thoughts
Within last month
One to six months
Six months or longer
None or unknown
Suicidal thoughts - please give further information including details of who is aware
Suicide plans
Within last month
One to six months
Six months or longer
None or unknown
Suicide plans - please give further information including details of who is aware
Suicide attempts
Within last month
One to six months
Six months or longer
None or unknown
Suicide attempts- please give further information including details of who is aware
Affected by the suicide of someone else e.g. family member or friend
Within last month
One to six months
Six months or longer
None or unknown
Affected by the suicide of someone else - please give further information including details of who is aware
Exposure to abuse
Within last month
One to six months
Six months or longer
None or unknown
Exposure to abuse - please give further information including details of who is aware
Parenting difficulties
Within last month
One to six months
Six months or longer
None or unknown
Parenting difficulties - please give further information including details of who is aware
Other
Within last month
One to six months
Six months or longer
None or unknown
Other - please give further information including details of who is aware
Protective Factors
What is going well right now for the person seeking support?
What helps the person seeking support cope with difficult emotions?
Who is helping the person seeking support? What support is in place?