Form Page | Gloucestershire Health and Care NHS Foundation Trust

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All parts of the form will be treated in complete confidentiality unless there is a concern that you or someone you know is at risk of harm. In order for us to get in touch, we’ll need you to provide a contact telephone number (either a landline or a mobile) and your school email address on the form. This information will only be used to contact you and will not be shared. *

Yes, I agree to provide you with a telephone number so you can contact me

Yes, I am happy for you to contact me by email

Although we will not share information we will need to tell a teacher or someone at the School that you have an appointment with us in order for you to be released from lessons. The reason for this appointment will be kept confidential. *

I confirm I understand and agree

The data you enter into the form will be in compliance with our GDPR policy. If you’d like to understand how we look after the information you give us in a confidential way, please visit: forms.ghc.nhs.uk

Are happy for us to contact you using the information you give us on this form *

Yes

The Mental Health Support Teams ARE NOT A CRISIS SERVICE. If you are unsafe or if you feel unable to keep yourself safe, please do not delay getting the help you need - forms.ghc.nhs.uk/crisis

Please confirm you understand this is NOT a crisis service. The team monitor referrals Monday-Friday – 9am-5pm and we will aim to contact you about your referral within 4 working days of the referral being submitted. *

Yes, I understand this is not a crisis service

Please select school: *

Name *

First Last

Gender *

Date of birth *

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Can we contact you at this address?

Yes

Home telephone number

Can we contact you on your home number?

Yes

Mobile phone number *

Can we leave a voicemail? *

Yes

How would you like us to let you know your appointment details? *

e.g. school email address, letter to your home address etc.

Would you prefer to be seen face to face in school or via an online virtual platform? *

Face to face

Online virtual platform

Your referral may be signposted to TiC+, please indicate your preference for contact with TiC+ *

Face to face

Online

Text chat

Telephone

Young person’s school or personal email address *

Name of school *

Start date at school *

GP surgery *

Ethnic origin

Do you care for a disabled or ill parent or older sibling?

Yes

Are you in foster care?

Yes

Do you have any physical or learning disabilities/health problems that we need to be made aware of?

Yes

Have you spoken to someone in the YMM team using the YMM chat text service

Yes

To help get you the best type of support, can you tell us about what is difficult for you at the moment?

For example what difficulties are you having? How long have they been affecting you? How do they affect you/your family, school work or friends?

Has anything happened in the past or recently to make you ask for help?

For example big family changes, illnesses or the death of a loved one?

Are you worried about your own safety or the safety of somebody else?

Never

Only occasionally

Sometimes

Often

Most of the time

Have you ever had thoughts of wanting to hurt yourself?

Never

Only occasionally

Sometimes

Often

Most of the time

When did you last have thoughts about hurting yourself? *

Have you ever had thoughts of not wanting to be alive anymore?

Never

Only occasionally

Sometimes

Often

Most of the time

When did you last have thoughts about not wanting to be alive? *

Have you ever acted on these thoughts?

Never

Only occasionally

Sometimes

Often

Most of the time

How long have you been having these thoughts?

Never

Only occasionally

Sometimes

Often

Most of the time

Where on the happiness scale do you currently sit?

What other agencies are currently supporting you? E.g. TiC+ or social care.

Do you give us permission to contact any of the agencies supporting you?

Yes

To accept your request for counselling we prefer to have the contact details of your parent/carer. We will not contact them unless you give us permission to do so (unless we are extremely concerned about your safety or the safety of somebody else).

Do we have your permission to contact the parent/carer if necessary?

Yes

Parent/carer name

First Last

Parent/carer phone number

Parent/carer email address

Parent/carer address - if different from yours

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please state the relationship of the parent/carer to this young person *

e.g. mother, father, guardian etc

Please provide us with a password. We will ask for the password when counselling takes place to check that the person is who they say they are. The password can be just one word that is easy to remember:

Please give us a memory jogger. If the password is forgotten this will be used to help remember it. E.g. if password is your pet's name, the memory jogger should be "pet's name":

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