"*" indicates required fields

Referrer Information

Is this referral for individual or group work? * REQUIRED

Consent Information

Please ensure a conversation has taken place with the young person and/or their parent/carer. It is essential that the young person's voice is heard. For secondary aged young people, please ensure a conversation has been had, and consent has been given by the young person, not just the parent/carer.
YMM continue to operate throughout the school holidays in venues external to schools. Young people will be expected to attend appointments offered outside school terms. Has this been discussed with parents and young people? * REQUIRED
Has consent been given for this referral? * REQUIRED
Is this referral for a primary aged child? * REQUIRED
In the event that YMM is unable to make contact with the parent/carer directly, do they consent to the child being seen without them present for the assessment in school ? * REQUIRED
Has the possibility of the referral being signposted, or discussed with one of our partner agencies, been discussed with the young person and/or parent carer? * REQUIRED
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Have you completed a Boxall Profile for this young person? * REQUIRED

Young person information

Is this young Person on the Graduated Pathway? * REQUIRED
DD slash MM slash YYYY
Interpreter required? * REQUIRED
Address * REQUIRED
Essential for secondary school aged person
Essential for secondary school aged person
The initial assessment will usually be face to face in the first instance, but there is a potential for an online assessment for those that prefer.
Your referral may be signposted to TiC+, please indicate your preference for contact with TiC+ * REQUIRED
Preferred contact for arranging appointments? * REQUIRED
Preferred method of contact for arranging appointments * REQUIRED

Parent/Carer information

Interpreter required? * REQUIRED
Does this person have parental responsibility? * REQUIRED
Does anyone else have parental responsibility? * REQUIRED
Address * REQUIRED

Household Information

Who else is living in the house?
Are they on a part-time timetable due to mental health needs? * REQUIRED

Summary of presenting needs

Presenting difficulties
Please tick appropriate option(s)
Does the young person have a disability, learning, psychological or sensory need? * REQUIRED
Is the young person on any medication? * REQUIRED
Are there any concerns around substance misuse? * REQUIRED
Is the young person known to social care? * REQUIRED
Is the young person a young carer? * REQUIRED
Is the young person on the Graduated Pathway? * REQUIRED
Please tell us which Pathway Plan. * REQUIRED
Is the young person a Looked After Child? * REQUIRED
Is the young person currently/previously open to CYPS? * REQUIRED
Does this young person have (or had previously) a Child Protection Plan? * REQUIRED
Any known self-harming behaviour in the last 3 months? * REQUIRED
Any known suicidal thoughts or acts? * REQUIRED
Either historical or current.
Are there any safeguarding concerns about this young person? * REQUIRED
Either historical or current.
Are there any siblings, or parents / care givers previously or currently known to mental health services?
Either historical or current.

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