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

Has your YP had any involvement with Mind and Body? Please select:

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

First name:

Last name:

Date of birth:

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

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 that you would like to share with us or feel relevant to share, including any medication?

(Yes - Details)

Do you have any allergies?

(Yes - Details)

Further Information

Occupation

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):