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Please complete this referral form as fully as possible. Any gaps may delay a decision.

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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, or this has been explained to them in an age appropriate way

The parent/carer has given consent for this referral, has read the privacy notice, and understands how their child’s and their information will be used and stored*

Yes - the parent/carer has given consent and read the privacy notice.

No – the child/young person is over 13 and has requested that the parent/carer not be made aware of this referral or contacted

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Referrer Details

Who is making this referral?*

Referrer Name*

Job title/relationship to the child/young person*

Referrer Type*

Agency Organisation (if professional referral)

Contact number

Address*

Email*

How did you hear about this service?

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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 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

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

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Details of child or young person being referred for support

Child / Young Person first name*

Child / Young Person last name*

Preferred name (if different from above)

Date of Birth*

Gender identity of child/young person

Is their gender identity the same as their gender assigned at birth?

Is the child/young person currently questioning their gender?

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 specify their accommodation status

Is their accommodation settled (stable)?

Name of School, college or education setting

Contact number of school, college or education setting

If not in school, please select from below

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

Is the child’s school part of the Emotional Well-being Team (Mental Health Support Team) programme delivered by the NHS?

If yes, has the child received support from this team?

If yes, what support did they receive and why do you feel a referral to this service is needed?

If no, have you consulted with Emotional Well-being Team lead in your school?

Why do you feel a referral to TSS is more appropriate?

Name of GP Surgery

GP Surgery Address

What is their NHS number? (please enter with NO spaces e.g. 1112223333)

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?

What language/s does the child/young person use?*

What is their ethnicity?*

What is their sexual orientation?

Is the child/young person currently questioning their sexuality?

Religion

Is the child/young person currently pregnant (Y/N)

Is the child/young person a Service Child (has a parent who is serving or has served in the armed forces)

Is the child/young person a Young Carer for a parent or sibling?

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Health

Does the child/young person have any long term health conditions or illnesses?

Please specify any long term health conditions or illnesses they have

Is the child/young person currently know to a Paediatrician?

Please give details on the young persons Paediatrician

Has the child/young person been seen by children's mental health teams previously?

Please give details on any mental health teams seen by the child/young person previously

Is the child/young person currently experiencing any phobias?

Does the child/young person have a diagnosed disability?

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

Home

Leisure activities

Is the child/young person autistic?

Please give details

Does the child/young person have Attention Deficit Hyperactivity Disorder (ADHD)?

Please give details

Does the child/young person identify as neurodivergent without formal diagnosis

Please give details

Does the child/young person have SEN Support in place?

Does the child/young person have an Educational Health Care Plan in place?

Does the child/young person have any allergies?

Please specify any allergies the child/young person may have

Please list all current prescribed medications (if known)

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Risks

Has the child/young person self-harmed within the past 6 weeks?

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?

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?

If yes please provide details

Has the child/young person ever expressed thoughts of not wanting to be alive?

If yes please provide details

Is the child/young person presenting with harmful sexual behaviours towards others?

If yes please provide details

Does the child/young person have a diagnosed eating disorder?

If yes please provide details (including if professional treatment was required)

Is the young person experiencing unusual or concerning eating patterns or behaviours?

If yes please provide details

Does the child/young person use substances (tabacco, vapes, alcohol, drugs, aerosols/gases)?

If yes please provide details

Is the child/young person vulnerable, or at risk to grooming/exploitation, including online harms

If yes please povide details

Is the child/young person violent or physically aggressive to others

If yes please provide details including most recent occurance

Does the child/young person actively put themselves in dangerous situations

Most recent occurrence

Type/Method

Is the child/young person known to Youth Offending Services, Criminal Justice System or an ongoing current police investigation?

If yes please provide details

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Additional support

Is the child/young person known to Early Help, Family Hubs or Family Solutions (Medway)

Name of assigned worker

Contact details

Is the child/young person considered a Child in Need?

If yes please provide details

Was the child/young person previously considered a Child in Need?

If yes please provide details

Is the young person subject to a Child Protection Plan?

If yes please provide details

Was the child previously subject to a Child Protection Plan

If yes please provide details

Is the child/young person open to Disabled Children’s Social Work Team?

If yes please provide details

Is the child/young person Care Experienced (have they at any time been looked after by a local authority)?

Is the child/young person a Care Leaver (looked after on or after their 16th birthday)?

Is the child/young person an adopted child?

Is the child/young person an Unaccompanied Asylum Seeking Child?

Does the child/young person have a Social Worker

Name of Social Worker

Contact number of Social Worker

Email of Social Worker

Manager Name

Is the Social Worker aware of this referral?

Is the child/young person a Child Looked After (LAC)

Date they went into care

Please state the type of placement they are in:

Please specify the type of placement they are in

Please give Keyworker/Managers Name:

Date they went into current placement:

Name of responsible Local Authority:

Legal Status under the Children's Act:

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)

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Please complete this referral form as fully as possible. Any gaps may delay a decision.

Consent

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Referrer Details

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Parent/Carer Details

If there is another appropriate/authorised contact please detail below:

Is there anyone that we should not share information with, and why?

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Details of child or young person being referred for support

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Health

Are you able to tell us the impact of the disability(ies) on the below:

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Reasons for Referral

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Risks

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Additional support

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