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Kent Therapeutic Support Service Referral Form
Referral Form - Kent Therapeutic Support Service
Step
1
of
8
- Consent
12%
Please complete this referral form as fully as possible. Any gaps may delay a decision.
Consent
Please state if you have been advised to make this referral by another professional or mental health scoring tool
*
Yes, I've been advised
No, I have not been advised
Please give details of who and/or what tool
Please state if the child and/or parent/carer are happy for us to share referral information to other Salus support services to help ensure that the child/young person gets the right level of support
*
Yes
No
Please state if the child and/or parent/carer are happy for us to share referral information to other services external to Salus to help ensure that the child/young person gets the right level of support
*
Yes
No
We may use the Kent and Medway Care Record (KMCR) to help inform the support we provide to the child / young person, and to help us improve services. If the child and/or parent/carer would like to opt-out of this, please tick this box
Yes, I'd like to
opt-out
You can find out more about how data is used in the Kent and Medway Care Record by viewing the
KMCR Privacy Notice
.
The child/young person has given consent for this referral to be made
*
The child/young person has given consent for this referral to be made
Has read privacy notice
*
The child/young person has read the
privacy notice
, and understands how their information will be used and stored
Parental consent
*
The parent/carer has given consent for this referral to be made
Parent read privacy notice
*
The parent/carer has read the
privacy notice
, and understand how their childs' and their information will be used and stored
Please indicate if the child/young person is over 13 and has requested that the parent/carer not be made aware of this referral or contacted
*
Yes
No
Please continue to next section
Referrer Details
Who is making this referral?
*
Please select...
I am a Professional
I am a Parent or Carer
I am making this referral for myself
Referrer Name
*
Job title/relationship to the child/young person
*
Agency Organisation (if professional referral)
Contact number
Address
*
Email
*
How did you hear about this service?
Please continue to next section
Parent/Carer Details
Parent/Carer name
Relationship to child/young person
Contact number
Address
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Email
Preferred method of contact
Please select...
Phone
Email
Either
Please can you confirm who has parental responsibility for the child/young person being referred?
Are there any reasons why someone with PR should not be contacted
Please select...
Yes
No
Not sure
If yes, please explain the reasons below
If there is another appropriate/authorised contact please detail below:
Name
Relationship to child/young person
Phone
Email
Address
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Is there anyone that we should not share information with, and why?
Name
Relationship to child/young person
Reason
Please continue to next section
Details of child or young person being referred for support
Child / Young Person name
*
Preferred name (if different from above)
Date of Birth
*
DD slash MM slash YYYY
Gender identity of child/young person
Please select...
Male (including trans man)
Female (including trans woman)
Non-binary
Other
Prefer not to say
Is their gender identity the same as their gender assigned at birth?
Please select...
Yes
No
Not known
Prefer not to say
Is the child/young person currently questioning their gender?
Please select...
Yes
No
Not known
Prefer not to say
Child/Young Person Contact number (if different from parent/carer)
Child/Young Person Email (if different from parent/carer)
Child/Young Person Address
*
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
What is their (their family) accommodation status?
Please select...
Owner occupier
Tenant (local authority)
Tenant (private landlord)
Living with other family members
Living with friends
University or College accommodation
Accommodation tied to job (including Armed Forces)
Mobile accommodation
Specialist Housing (with adaptations to meet needs)
Bed and Breakfast accommodation to prevent or relieve homelessness
Hostel to prevent or relieve homelessness
Temporary housing to prevent or relive homelessness
Admitted patient setting
Other (please specify)
Not known
Please specify their accommodation status
Is their accommodation settled (stable)?
Please select...
Yes
No
Not known
Name of School, college or education setting
Contact number of school, college or education setting
If not in school, please select from below
Please select...
Not in Education, Employment or Training (NEET)
Home Educated
Missing Education
Awaiting Placement
Attending Alternative Provision
In training
In employment
Please highlight if the child/young person will or has missed 15 days of school due to medical/health needs during the current academic year
Please select...
Yes
No
Not known
Name of GP Surgery
GP Surgery Address
What is their NHS number?
We ask for your NHS number to help us to co-ordinate support with other providers, and to report to the NHS for planning and research. Please see the
Privacy Notice
for more detail.
If you don't know the NHS number, do you give permission for us to look this up using the NHS Spine System?
Please select...
Yes
No
Not known
What language does the child/young person use?
*
What is their ethnicity?
*
Please select...
White British
White Irish
Gypsy Roma
Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
Indian
Pakistani
Bangladeshi
Any other Asian background
Caribbean
African
Any other Black background
Chinese
Any other ethnic group
Not stated
Not known
What is their sexual orientation?
Please select...
Heterosexual/straight
Bisexual
Gay male
Gay female/lesbian
Other
Prefer not to say
Not known
Is the child/young person currently questioning their sexuality?
Please select...
Yes
No
Not sure
Religion
Please select...
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Other
No religion
Prefer not to say
Not known
Is the child/young person currently pregnant (Y/N)
Please select...
Yes
No
Not known
Is the child/young person a Service Child (has a parent who is serving or has served in the armed forces)
Please select...
Yes
No
Not known
Is the child/young person a Young Carer for a parent or sibling?
Please select...
Yes
No
Not known
Please continue to next section
Health
Does the child/young person have any long term health conditions or illnesses?
Please select...
Yes (please specify)
No
Not known
Please specify any long term health conditions or illnesses they have
Is the child/young person currently know to a Paediatrician?
Please select...
Yes (please give details)
No
Not known
Please give details on the young persons Paediatrician
Has the child/young person been seen by children's mental health teams previously?
Please select...
Yes (please give details)
On a waiting list
No
Not known
Please give details on any mental health teams seen by the child/young person previously
Is the child/young person currently experiencing any phobias?
Please select...
Yes (please give details)
No
Not known
Does the child/young person have a diagnosed disability?
Please select...
No
Physical
Sensory (hearing, sight or both)
Longstanding illness or health condition, such as cancer, HIV/AIDS, heart disease, diabetes or epilepsy
Mental health condition
Learning disability
Neurodivergent such as ADHD, autism, dyslexia and dyspraxia
I prefer not to say
A different disability or health condition (please tell us)
Not known
Please tell us about the child/young person's disability or health condition
Are you able to tell us the impact of the disability(ies) on the below:
School
Please select...
Limited a lot
Limited a little
Not limited
Home
Please select...
Limited a lot
Limited a little
Not limited
Leisure activities
Please select...
Limited a lot
Limited a little
Not limited
Does the child/young person have Autism?
Please select...
Yes - with a diagnosis
On waiting list for assessment
No
Not known
Please give details
Does the child/young person have Attention Deficit Hyperactivity Disorder (ADHD)?
Please select...
Yes - with a diagnosis
On waiting list for assessment
No
Not known
Please give details
Does the child/young person identify as neurodivergent without formal diagnosis
Please select...
Yes (please give details)
On waiting list for assessment
No
Not known
Please give details
Does the child/young person have SEN Support in place?
Please select...
Yes
No
Requested but not in place yet
Not known
Does the child/young person have an Educational Health Care Plan in place?
Please select...
Yes
No
Requested but not in place yet
Not known
Does the child/young person have any allergies?
Please select...
Yes (please specify)
No
Not known
Please specify any allergies the child/young person may have
Please list all current prescribed medications (if known)
Please continue to next section
Reasons for Referral
From the list below, please select any factors that are present for the child/young person:
Currently engaging in or at risk of Coercive and/or Abusive Relationships
Previously experienced or currently at risk of familial Domestic Abuse
Experiencing harmful conflict (between adults)
Family experiencing financial difficulties or living in poverty
Unemployed or Economically Inactive family members
Experienced bereavement
Experienced trauma
Victim of bullying
Experiencing anxiety
Low self-esteem, self-confidence and resilience difficulties
Anger difficulties
Issues around behaviour support
Exam stress
Adjustment and transition stress
Attachment and/or relationship difficulties with family and peers
Disengagement from education and training
Currently at risk of offending
Please describe in as much detail as possible the concerns and issues the child/young person is experiencing
*
How do the above concerns and issues impact on the child/young person at home, in education and during leisure time?
*
Please can you describe the family home environment. Who lives at home? Do any parents/carers have any mental or physical health needs? Sibling dynamics. Any other stressors. Positive support
*
Please list any services or interventions that the child/young person/family has tried prior to making this referral
What has helped in the past?
Child/young person outcomes: What hopes or expectations does the child/young person have from this referral?
Parent/Carer outcomes: What hopes or expectations does the parent/carer have from this referral?
Referrer outcomes: What hopes or expectations does the referrer have from this referral?
Any additional comments
Please continue to next section
Risks
Has the child/young person self-harmed within the past 6 weeks?
Please select...
Yes
No
Most recent occurrence
Type/Method
Was professional treatment required? (if yes please give details)
Has the child/young person ever taken an overdose of tablets, medication or another substance?
Please select...
Yes
No
Most recent occurrence
Was professional treatment required? (if yes please give details)
Has the child/young person ever made an attempt to end their life?
Please select...
Yes
No
If yes please provide details
Has the child/young person ever expressed thoughts of not wanting to be alive?
Please select...
Yes
No
If yes please provide details
Is the child/young person presenting with harmful sexual behaviours towards others?
Please select...
Yes
No
If yes please provide details
Does the child/young person have a diagnosed eating disorder?
Please select...
Yes
No
If yes please provide details (including if professional treatment was required)
Is the young person experiencing unusual or concerning eating patterns or behaviours?
Please select...
Yes
No
If yes please provide details
Does the child/young person use substances (tabacco, vapes, alcohol, drugs, aerosols/gases)?
Please select...
Yes
No
If yes please provide details
Is the child/young person vulnerable, or at risk to grooming/exploitation, including online harms
Please select...
Yes
No
If yes please povide details
Is the child/young person violent or physically aggressive to others
Please select...
Yes
No
If yes please provide details including most recent occurance
Does the child/young person actively put themselves in dangerous situations
Please select...
Yes
No
Most recent occurrence
Type/Method
Is the child/young person known to Youth Offending Services, Criminal Justice System or an ongoing current police investigation?
Please select...
Yes
No
If yes please provide details
Please continue to last section
Additional support
Is the child/young person known to Early Help, Family Hubs or Family Solutions (Medway)
Please select...
Yes
No
Name of assigned worker
Contact details
Is the child/young person considered a Child in Need?
Please select...
Yes
No
If yes please provide details
Was the child/young person previously considered a Child in Need?
Please select...
Yes
No
If yes please provide details
Is the young person subject to a Child Protection Plan?
Please select...
Yes
No
If yes please provide details
Was the child previously subject to a Child Protection Plan
Please select...
Yes
No
If yes please provide details
Is the child/young person open to Disabled Children’s Social Work Team?
Please select...
Yes
No
If yes please provide details
Is the child/young person Care Experienced (have they at any time been looked after by a local authority)?
Please select...
Yes
No
Not known
Is the child/young person a Care Leaver (looked after on or after their 16th birthday)?
Please select...
Yes
No
Not known
Is the child/young person an adopted child?
Please select...
Yes
No
Not known
Is the child/young person an Unaccompanied Asylum Seeking Child?
Please select...
Yes
No
Not known
Does the child/young person have a Social Worker
Please select...
Yes
No
Name of Social Worker
Contact number of Social Worker
Email of Social Worker
Manager Name
Is the Social Worker aware of this referral?
Please select...
Yes
No
Is the child/young person a Child Looked After (LAC)
Please select...
Yes
No
Date they went into care
Please state the type of placement they are in:
Please select...
Foster placement
Residential home
Shared accommodation
Supported accommodation
Reception Centre
Other (please specify)
Please specify the type of placement they are in
Please give Keyworker/Managers Name:
Date they went into current placement:
DD slash MM slash YYYY
Name of responsible Local Authority:
Legal Status under the Children's Act:
Please select...
Accommodated (Section 20)
Emergency Care Order (Section 48)
Full Care Order (Section 31)
Interim Care Order (Section 38)
Police Protection Order (Section 46)
Special Guardianship Order
Not known
Please list any other Health or Social Care Professionals currently supporting the child/young person and/or the family that have not already been named
Agency
Contact Name
Contact Number
Support provided (if known)
Δ
