Referral Form

Important: Mind of the Student offers education based, early intervention and low-level mental health support. We do not provide level 2, 3, or 4 mental health services. If the young person requires more specialised support, please contact your local CAMHS team through their GP. Referrals may be declined if we determine that the young person would benefit more from specialist mental health support or services beyond what we can currently provide. Our priority is ensuring that every individual receives the most appropriate support for their needs.

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Please select the programme you would like to register for or be referred to: *

Child or young person's details

Young Person's Legal Name *

First

Last

Family name if different to theirs

Date of birth *

Child or young person's contact information

Phone *

Email *

Address *

Town *

County *

Postcode *

Child or young person's background

Ethnicity *

What gender does the young person identify with? *

First language *

Is the young person a carer for a family member? *

Is the young person a Looked After Child (LAC)? *

Does the young person have a family member serving in the military or who is ex-military? *

GP Details

Young person's GP

Young person's GP contact details

Education

Is the young person in education or training (including home schooling)? *

Does the young person have a formal EHCP (Education Health Care Plan) through the local authority *

Is the young person being homeschooled? *

School/pre-school/college *

Contact person at school *

About the principle parents / main carers

Principle Parents First Name *

Principle Parents Last Name *

Relationship to the young person *

Principle Parents Address *

Principle Parents Phone *

Principle Parents Email *

Does this person have parental responsibility?

If no, please enter the name and contact details for the person who does have parental responsibility

Reason for referral

Please describe any mental health difficulties they might be having, e.g. worries, sadness, anger, changeable moods or feelings, self-harm etc *

How long have these been affecting them? *

What impacts have these had on the young person, and have these had any impact on their family, school work or friends? *

Has anything happened recently to make them seek help at this time? *

Is there any further information that you/they think we should know? *

Referrer

If you are completing this as a parent or guardian, and have already entered your details above, please leave the below fields blank.

Referrer First name

Referrer Last name

Job Title

Organisation

Referrer Email

Referrer Phone

Information sharing

Mind of the Student collaborates with trusted partners, including schools, charities, and mental health professionals, to provide effective support for young people. To ensure you receive the best possible care without having to repeat information, we only share the minimum necessary details with relevant organisations that contribute to your wellbeing. By engaging with Mind of the Student, you consent to us securely sharing relevant information with these partners to help provide the support you need. All information is held securely, and access is controlled in accordance with the Data Protection Act 1998. You can read our full privacy policy here: www.mindofthestudent.org/privacy I agree to information being shared between agencies. *

Consent Given By *