Information Sharing Form – Child or Young Person "*" indicates required fields Step 1 of 7 – Consent 14% The Emotional Wellbeing Hub is for children and young people aged 0-25 who are concerned about their emotional wellbeing. You can use this form to tell us about yourself, and a practitioner from the Hub will contact you to discuss your concerns with you. You can fill out as much or as little as you like, but please remember to tell us how to get in touch with you. For a medical emergency, dial 999.If you are under the age of 16, does your parent or carer know that you are contacting the Hub?* Yes No Can we speak to your parent or carer?* Yes No If we are concerned that you or someone else might get hurt, we may need to speak with other adults about it, including your parent or carer. How are you feeling? What are you worried about? OptionalWhat has happened in the past that makes you concerned? OptionalHow has this impacted on your ability to do what you need to do each day? OptionalHow are things going at school (or at work), at home, with family and with friends? OptionalAre there people or things that make things worse? OptionalWhat is working well? Are there people or things that help? OptionalWhat do you think needs to happen next to address your concerns? Optional On a scale from 0 to 10, how safe are you at the moment? OptionalPlease select…0 – I feel unsafe12345678910 – I feel safeWhat are you worried will happen? Who or what makes you feel unsafe? OptionalHave you harmed yourself or has someone harmed you in the past? What happened? OptionalWho or what helps you stay safe? OptionalWhat needs to happen to help you stay safe? Optional In coming to this service, what would you like to be different or what are the main goals you want to get to? What is your first goal? OptionalHow close are you to reaching your first goal today? OptionalPlease select…0 – Goal not met at all12345 – Halfway to reaching this goal678910 – Goal reachedWhat is your second goal? OptionalHow close are you to reaching your second goal today? OptionalPlease select…0 – Goal not met at all12345 – Halfway to reaching this goal678910 – Goal reachedWhat is your third goal? OptionalHow close are you to reaching your third goal today? OptionalPlease select…0 – Goal not met at all12345 – Halfway to reaching this goal678910 – Goal reached Name* Please select…MasterMrMrsMissMsMx Title First Last Date of Birth* Day Month Year Which best describes your gender identity?*Please select…FemaleMaleOtherPrefer not to answerIf you selected ‘Other’, please tell us how you describe your gender identity: OptionalEthnicity OptionalPlease select…White – BritishWhite – IrishWhite – Any other White backgroundMixed – White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianMixed – Any other mixed backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian or Asian British – Any other Asian backgroundBlack or Black British – CaribbeanBlack or Black British – AfricanBlack or Black British – Any other Black backgroundOther Ethnic Groups – ChineseOther Ethnic Groups – Any other ethnic groupNot Stated – Not StatedNot known – Not knownHome Phone OptionalMobile Phone OptionalAddress Street Address Optional Address Line 2 Optional Town/City Optional Post Code Optional School OptionalName of GP Practice OptionalName of your GP OptionalNHS Number (if known) Optional Contact details for your family members and other important people (please include your parents or carers)Please enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address: OptionalPlease enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address: OptionalPlease enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address: OptionalPlease enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address: OptionalPlease enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address: OptionalPlease enter the person’s details including first name, surname, relationship to yourself, phone number, email address and postal address: Optional Please enter the service's details including the name of the service, the keyworker’s name, their phone number, postal address and when you last had contact with this service: OptionalPlease enter the service's details including the name of the service, the keyworker’s name, their phone number, postal address and when you last had contact with this service: OptionalPlease enter the service's details including the name of the service, the keyworker’s name, their phone number, postal address and when you last had contact with this service: OptionalPlease enter the service's details including the name of the service, the keyworker’s name, their phone number, postal address and when you last had contact with this service: OptionalAnything else? Optional This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.