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Ainsley Bailey
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Steve Brown
Yvonne Minto
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Referrals
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Mentee Referral Form
Name
Email
Address
Pronouns
Ethnicity
Contact number:
Parent/Legal Guardian Name:
Relationship to child:
Please tick all the criteria that apply:
Is a child in care
Is at risk of exploitation
Has a disability
Receiving SEND support at school
Has an Education and Health Care plan
Is on a child protection plan
Please give details of relevant key workers Eg, Social Worker / Teacher / Youth Justice Worker
Key worker name:
Job title:
Organisation:
Contact number:
What schooling/education do you receive:
Is the young person known to CAMHS?
Refferer Details
Refferer Name:
Job Title:
Organisation:
Date of Referral:
Contact Number:
Email:
What is the reason for referral?
What are your biggest concerns? (please tick all that apply)
Harm to self
Harm from others
Anxiety/worry
Depression/low mood
Physical health/illness
COVID-19
Bereavement
Caring responsibilities
Employability
Offending behaviour
Personal safety
Family problems/home life
Sexual Health
Community involvement
Discrimination
Sexuality or gender issues
Education support
Domestic Abuse
What goal would you like to work towards?
What needs to happen to improve things for the Young Person? (please tick all that apply)
Community involvement
Explore hobbies/interests
Learn new coping strategies
Learn independent living skills
Healthier lifestyle habits
Crisis planning
Make plans for future
Feel safer
Better relationships at home
Access support/services
Make friends
Other (describe below)
What goal would the young person like to work towards? Please ensure this reflects the young person’s wishes.
Please give details about risk assessment and management below - Give details of risk to self and others:
Please tick to confirm the child is aware of and in agreement with this referral
Please tick to confirm the parent/legal guardian is aware of and in agreement with this referral - if child is under 13 and is unable to consent.
Send
