Washington Mind Young People’s Project Referral (Ages 11 to 18)

Washington Mind Young People’s Project Referral (Ages 11 to 18)

(for referring on a young person's behalf)
Please complete the form below with as much accurate information as possible in order for us to process the referral and appropriate support to the young person.

If this form is not fully completed, we will be unable to offer a triage appointment and we will inform you of this.

If a young person is a significant risk to self/actively suicidal with plan, please ADVISE A&E IMMEDIATELY or contact the Children and Young People’s Crisis Team via the NHS 111 Mental Health Team which can be reached by calling: 111 and dialling option: 2
Who is making this referral?
Name of person making this referral*

First NameLast Name
Email address for personal making this referral*
example@example.com
Contact Number for person making this referral*
Please enter a valid phone number.Format: 0000 000 0000.
Date of referral*

DayMonthYear
Date
About the young person you're referring
Name of person you're referring*

First NameLast Name
Their preferred name
Phone Number*
Please enter a valid phone number.Format: 0000 000 0000.
YesNo
YesNo
DOB*

DayMonthYear
Date
Gender*
Address*

Address Line 1

Address Line 2

CityTown

Post Code
YesNo
YesNo
YesNo
Ethnicity:*
YesNo
School / College:*
Next of Kin / Relationship:*
Next of Kin / Phone Number:*
Please enter a valid phone number.Format: 0000 000 0000.
About the referral
Reason for referral:*
Young Person’s expected outcome:*
Referrer’s expected outcome:*
Risk assessment and protective factors

Please include a thorough assessment of risk and mental health concerns, or include your own attached triage or relevant information (if available) when returning this form.
Past Risk:*
Current Risk:*
Name of GP Practice:*
Professional involvement

Type a question*

Rows	Involved Y / N	Dates of involvement	Please detail the type of work which was undertaken
Early Help
Crisis Team
CYPS
Safeguarding
SCCYMPS (previously CCAMHS)

Please detail any other professionals involved below:

Rows	Name	Title	Tel No:	Involvement
Professional 1
Professional 2
Professional 3

Should be Empty:

Washington Mind Young People’s Project Referral (Ages 11 to 18)

Who is making this referral?

About the young person you're referring

About the referral

Risk assessment and protective factors

Professional involvement