Parent/Carer Referral Form - YMCA Exeter Wellbeing Service

Please note the following:
- This referral form is to be completed by Parents/Carers only of young people aged between 5 - 12 wishing to access our service. If a child/young person you wish to refer is between 13 and 18 years, please encourage and support them to complete the Self-Referral form on our website instead.
- PLEASE NOTE: If the child or young person is at risk of harm to themselves or others, please contact their GP to discuss a safety plan as we are not able to provide emergency care. All information given will be treated as strictly confidential.
- If you have any queries/problems with this, please get in touch with us by either calling 01392 410530 or emailing us at wellbeing@ymcaexeter.org.uk.
Before proceeding, please read carefully:

By ticking this box, you confirm that your child is not currently experiencing any of the following:
- Trauma
- Eating disorders
- Complex family relationships
- Grief/bereavement
- Actively being bullied
- School avoidance for a significant amount of time
I understand that if my child is currently experiencing any of the concerns listed above, this referral may not be considered appropriate at this time.
I confirm that I have read the above
Parent/Carer details
Name *

First NameLast Name
Email *
example@example.com
Phone Number *
How do you prefer to be contacted?*
We will do our best to reach you using the preferred contact details you provided. If we are not able to reach you using your preferred contact method, we may try other ways to get in touch. Please double-check that your information is accurate and that you are happy for us to contact you via the details provided.
Is there a preferred time to contact you? If so, please specify days and times.*
Any other relevant information:*
Permission to leave voicemails:*

YesNo
Child or young person's details
Name *

First NameLast Name
Preferred Name*
Date of Birth *

DayMonthYear
Child or young person’s NHS number:*
(If unknown, please state unknown)
Phone Number *
Email *
Address *

Street Address

Street Address Line 2

CityRegion

Postcode
Describe gender*
Does this child or young person have a disability?*

YesNoPrefer not to say
If yes, please specify*
Please type N/A if answer was No or Prefer not to say to previous question
Does this child or young person require constant supervision or care due to a disability?*

YesNo
Is this child or young person a Young Carer?*

YesNo
If yes, please specify who are they are a Young Carer for: *
Please type N/A if answer was No to previous question
Accommodation Status: (Please tick the relevant option)*

Parent or carer owns/rents the houseTemporary accommodationSofa surferSupported lodgings
If an alternative answer to question, please specify:*
Please type N/A if there is no alternative answer to previous question.
Ethnicity:
(Please tick appropriate box)*

White and Black CaribbeanWhite and Black AfricanWhite and AsianWhite BritishWhite IrishWhite otherIndianPakistaniBangladeshiCaribbeanAfricanOther
If "Other" to any of the above ethnic groups, please specify:*
Please type N/A if "Other" option was not used.
Prefer not to say
Long Term Condition Status:(Please tick the relevant option)*

AsthmaCancerChronic painDiabetesEpilepsyHeart FailureMedically UnexplainedConditionsNo Long-Term Health Conditions
Child Protection Plan: (Please tick the relevant option)*

Has never been subject to a Child Protection PlanHas previously been subject to a Child Protection PlanIs currently subject to a Child Protection Plan
Is this child or young person a Looked After Child? (In public care, living with foster carers, in residential homes or with other relatives)*

YesNoPrefer not to say
Who is this child or young person’s Education provider? *
(E.g., School name, College name, Apprenticeship)
School Year: *
GP Practice: *
(If unknown, please state unknown)
Who is the child or young person’s registered GP? *
(If unknown, please state unknown)
Do you consent for this child or young person’s data to be kept confidentially on YMCA Exeter’s record? Note: without this consent to store your data we are unable to provide support.*

YesNo
Our Wellbeing Practitioners also offer evidence-based Low Intensity CBT group sessions. Would you like to be considered for groupwork?*

YesNo
REASON FOR REFERRAL

please provide as much information as possible to the following questions.
What are the main symptoms experienced? *
How long has this young person been presenting symptoms? How often do these symptoms occur?*
What is the impact of these symptoms on their day-to-day life?*
What kind of support do you feel would benefit this young person?*
Please let us know if any other professionals ARE working with your family currently (and if so, what support are they providing?)*
Please type NONE if this question is not applicable.
Please let us know if any other professionals HAVE worked with this family within the last year (and if so, what support they provided, and when was this?)*
Please type NONE if this question is not applicable.
Are there any concerns or risks related to your child's safety (risk to self, risk to others, risk from others)? If yes, please provide details:*
Please give additional information you feel would be helpful for us to know when processing your referral:*
YMCA Exeter Wellbeing Practitioner Information Sharing Consent Form

I agree to the information collected within this form, sessions with a Wellbeing Practitioner, and any other supporting information provided, to be shared with the following:
- Other professionals within YMCA Exeter
- Relevant health and social care organisations
- Agencies including the Department of Health for wider data collection to support our evidence base.
This includes, if required:
- Children’s centres
- Your GP
- CAMHS services and education
This is for your family to receive the best possible service, but on the basis that this will be done securely. Information is only ever shared on a need-to-know basis and always to ensure the care of the child.

Sharing information will always be completed in line with the General Data Protection Regulation and Caldicott Principles.

I understand that I can withdraw my consent to the sharing of my and/or my child’s personal information at any time and agree to inform the relevant professional if I wish to do so. However, I am aware that if consent is withdrawn, provision of services may not be possible.

I understand that I have the right to know where and with whom my information is shared, and that I can contact YMCA Exeter if I need assistance on understanding how information is managed.

I understand that information may need to be shared without my permission if the safety of my child/children/family or any other person is at risk, or for legal purposes. This could include where information is needed to help stop or solve a crime.

I understand that any information about me and my family will be held securely by YMCA Exeter and that my personal information is protected by the Data Protection Act 2018. It will not be held for any longer than necessary in line with our data retention policy.
Name of Child or Young Person: *
Date of Birth: *

DayMonthYear
Name of person completing this form: *
Relationship to Child: *
Today’s date: *

DayMonthYear
Signature

Upload electronic signature if you have one
Cancelof
If you do not have an e-signature, please type your name here: *
Is there any information you prefer to not be shared or any person/organisation you would not want your information shared with? *
RECORDING:

A big part of our team is made up of trainee practitioners, and as part of their training, they are expected to record all sessions with young people.

By referring yourself to this service, you will be agreeing to being recorded for Assessment and Intervention sessions.

These recordings are kept securely. If this is a problem for you, please do let us know and we can discuss further with you. Not being recorded is an option, but you may have to wait a bit longer to be seen by an alternative practitioner.

Thank you for your understanding and for supporting our practitioners in their training.
If you require any additional assistance with completing the referral form, please contact us on 01392 410530.
By submitting this form, you confirm that you have read and consented to our Attendance Agreement on our website.*

I Agree
Should be Empty:

Parent/Carer details

Child or young person's details

Ethnicity:

REASON FOR REFERRAL