"*" indicates required fields Referrer InformationReferrer name * REQUIREDSchool name * REQUIREDPlease select oneAbbeymead Primary SchoolAll Saints AcademyArchwayAveningAylburton CofE Primary SchoolBalcarras SchoolBarnwood Park Arts CollegeBarnwood Park SchoolBarnwood CofE Primary SchoolBeech Green Primary SchoolBelmont SchoolBerry Hill Primary SchoolBlakeney Primary SchoolBream CofE Primary SchoolBromesberrow St Mary's CofE Primary SchoolBussageCallowellCalton Primary SchoolCam EverlandsCam WoodfieldCarrant BrookCashes GreenCatholic School of St Gregory the GreatCheltenham Bournside School and Sixth Form CentreChesterton Primary schoolChosen Hill SchoolChrist Church SchoolChurchdown School AcademyChurchdown Village Junior SchoolChurchdown Parton Manor Junior SchoolCirencester Deer ParkCirencester PrimaryClearwell CofE SchoolCleeve Secondary SchoolCoalway Junior SchoolConey Hill Community Primary SchoolCoopers Edge SchoolDene Magna SchoolDenmark Road High SchoolDinglewell Junior SchoolDrybrook Primary SchoolDunalley Primary SchoolDursleyElmbridge Primary SchoolField Court Junior AcademyFinlay Community SchoolFive Acres High School (formerly Lakers)Forest View Primary SchoolGardners Lane Primary School (Federation w/ Oakwood)Glebe Infants (Newent Federation of Schools)Glenfall Community Primary SchoolGLOSCOL - NEW Forest of Dean CollegeGloucester AcademyGloucester Road Nursery and Primary SchoolGrange Primary SchoolGreatfield Park Primary SchoolHarewood Junior SchoolHeron Primary SchoolHempsted CofE Primary SchoolHenley Bank High SchoolHestersway Primary SchoolHillview Primary SchoolHolmleigh Park High SchoolHoly Trinity CofE Primary SchoolHope Brook CofE Primary SchoolHuntley CofE Primary SchoolHunts Grove Primary SchoolInnsworth Junior SchoolJohn MooreKingsholm CofE Primary SchoolKingshill SchoolKingsway Primary SchoolLakeside Primary SchoolLinden Primary SchoolLonglevens Junior SchoolLydbrook Primary SchoolLydney CofE Community SchoolMaidenhillMeadowside Primary SchoolMitcheldean Endowed Primary SchoolMitton ManorMoat Primary AcademyNewent Community School and Sixth Form CentreNewnhamOakwood Primary (Federation wi/ Gardners Lane)Parkend Primary SchoolPauntley CofE SchoolPicklenash Junior School (Newent Federation of Schools)PillowellPittville Secondary SchoolPowellsPrimrose Hill C of E Primary Academy SchoolQueen MargaretRedbrook CofE PrimaryRednockRibston Hall High SchoolRobinswood Primary AcademyRowanfield Junior SchoolRuardean C of E Primary SchoolSevernbanks Primary SchoolSevern Vale SchoolSir Thomas Rich’s SchoolSir William RomneySoudley Primary SchoolSpringbank Primary AcademySt Briavels Parochial CofE Primary School (Wye Forest Federation)St James CofE Junior SchoolSt. James Primary SchoolSt John's CofE AcademySt Johns Primary SchoolSt MarysSt Pauls CofE Primary SchoolSt Peter’s Catholic School and sixth form centreSt. Peter's Catholic Primary SchoolSt Thomas More Catholic Primary SchoolSt White's Primary SchoolSteams Mill PrimaryStroud ValleyTewkesbury CofETewkesbury Secondary schoolThe Crypt SchoolThe Dean AcademyThe Forest High SchoolThe GrangeThe Highschool LeckhamptonThomas KebleTredworth Junior SchoolTutshill School CofEUpton St Leonards CofE Primary SchoolWatermoor SchoolWalmore Hill Primary SchoolWaterwells Primary SchoolWidden Primary SchoolWillow Primary SchoolWoodside Primary SchoolWoolaston Primary SchoolWyedean School and Sixth Form CentreYorkley Primary SchoolJob title * REQUIREDReferrer Contact Telephone * REQUIREDReferrer's Email * REQUIRED If at primary school, please give the class teacher’s email address Is this referral for individual or group work? * REQUIRED Individual Group If you have selected group, has this been discussed with a member of the YMM team? If so, who?Consent InformationPlease 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 Yes No Has consent been given for this referral? * REQUIRED Yes, by the young person (for all referrals) Yes, by parent/carer No Is this referral for a primary aged child? * REQUIRED Yes No 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 Yes No 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 Yes - young person Yes - parent/carer Yes - both No This field is hidden when viewing the formHave you completed a Boxall Profile for this young person? * REQUIRED Yes No Young person informationFull name * REQUIREDWhat is the young persons preferred pronouns?Is this young Person on the Graduated Pathway? * REQUIRED Yes No Preferred nameDate of Birth: * REQUIRED DD slash MM slash YYYY Gender * REQUIREDPlease SelectFemaleMaleNot specifiedSchool year * REQUIREDReligion * REQUIREDEthnicity * REQUIREDUk Residence StatusPlease select one:Asylum seekerNon UK resident (lived in UK less than 6 months)Overseas studentPrivate patientRefugeeUK resident (lived in UK for at least the last 6 months)Preferred language * REQUIREDInterpreter required? * REQUIRED Yes No Address * REQUIRED Address Line 1 Address Line 2 City Post code Young person's school or personal emailEssential for secondary school aged personYoung person's mobile numberEssential for secondary school aged personThe 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. Face to face Online Your referral may be signposted to TiC+, please indicate your preference for contact with TiC+ * REQUIRED Face to face Online Text chat Telephone GP Surgery Name * REQUIREDGP Phone numberPreferred contact for arranging appointments? * REQUIRED Directly with young person With parent/carer Preferred method of contact for arranging appointments * REQUIRED Email Leave a message with parent/carer or other person Letter home Mobile (call) Other person contact detailsParent/Carer informationParent/carer full name * REQUIREDRelationship to young person * REQUIREDParent/ carer phone number * REQUIREDEmail address Preferred language * REQUIREDInterpreter required? * REQUIRED Yes No Does this person have parental responsibility? * REQUIRED Yes No Does anyone else have parental responsibility? * REQUIRED Yes No Their full name * REQUIREDAddress * REQUIRED Street Address Address Line 2 City Post code Phone * REQUIREDEmail * REQUIRED Relationship to young person * REQUIREDHousehold InformationWho else is living in the house?Please give the name, date of birth (if known), school attending (if applicable) and relationship to the young person for each person living in the household. * REQUIREDHome life and parents / care givers views. * REQUIREDCurrent school attendance (percentage) * REQUIREDAre they on a part-time timetable due to mental health needs? * REQUIRED Yes No Summary of presenting needsPresenting difficulties Worry/anxiety Low mood Phobia Emotional regulation Behaviour (children under 10) Sleep Repetitive behaviours Please tick appropriate option(s)Please give a description of the young person's current emotional or mental health difficulties, indicating the frequency/severity of these behaviours and difficulties and how these are impacting on the child, family or their education. Please try to include the young person's view as well as yours, and the parents/carers if appropriate. When was the difficulty first noticed? Would you describe it as mild or moderate? What has been tried before in terms of support? Are there multiple agencies involved? Are there any communications challenges that might interfere with treatment (including for the parents)? Are you aware of any complex needs eg eating disorder, PTSD, significant trauma or risk? * REQUIREDWhat support is the school providing to the young person at this time? * REQUIREDWhat would the Young Person like to get out of support from the mental health support team. * REQUIREDDoes the young person have a disability, learning, psychological or sensory need? * REQUIRED Yes No Please state any reasonable adjustments required.Is the young person on any medication? * REQUIRED Yes No Please provide details of the medication * REQUIREDAre there any concerns around substance misuse? * REQUIRED Yes No Please provide details of the substance misuse concernsIs the young person known to social care? * REQUIRED Declined to disclose No Yes (currently) Yes (previously) Please provide details of social care worker * REQUIREDIs the young person a young carer? * REQUIRED Declined to disclose Yes No Not known Please provide details of care responsibilities. * REQUIREDIs the young person on the Graduated Pathway? * REQUIRED Yes No Please tell us which Pathway Plan. * REQUIRED My Plan My Plan+ EHCP Is the young person a Looked After Child? * REQUIRED Yes No Not known Is the young person currently/previously open to CYPS? * REQUIRED Yes (currently) Yes (previously) No Declined to disclose Does this young person have (or had previously) a Child Protection Plan? * REQUIRED Yes (currently) Yes (previously) No (never been subject to a CPP) Not known Any known self-harming behaviour in the last 3 months? * REQUIRED Yes No Not known Details of self-harming behaviour * REQUIREDAny known suicidal thoughts or acts? * REQUIRED Yes No Not known Either historical or current.Details of suicidal thoughts or acts * REQUIREDAre there any safeguarding concerns about this young person? * REQUIRED Yes No Either historical or current.Details of safeguarding concerns * REQUIREDAre there any siblings, or parents / care givers previously or currently known to mental health services? Yes No Either historical or current.Details of current or previous engagement. * REQUIREDWorking SafelyCAPTCHA