Parent/Carer (for a person 0-25 years) & Professionals (for a person 18-25) referral form “*” indicates required fields Step 1 of 9 – Initial Screening 11% Initial screening This form is designed for parents, carers, practitioners and other concerned adults who are seeking support from the Emotional Wellbeing Hub regarding a child or young person’s mental health or emotional wellbeing. The Hub is for children and young people aged 0-25 who are registered with a GP in East or West Suffolk. For a medical emergency, dial 999. For URGENT advice, signposting and access to crisis response please contact NHS 111 and select the mental health option.Please tick any that apply Requires an urgent response from the Hub Optional Optional Requires assessment for First Episode Psychosis Optional Optional Requires assessment for Eating Disorders Optional Optional Please give additional details if you have ticked any of the boxes above: Optional Optional Details of the concerned adult or referring professionalName First Optional Optional Last Optional Optional Role//relationship to the young person Optional OptionalService/team/organisation (if applicable) Optional OptionalHome/office phone number Optional OptionalMobile phone number Optional OptionalEmail Enter Email Optional Optional Confirm Email Optional Optional Address Address Line 1 Optional Optional Address Line 2 Optional Optional Town Optional Optional Postcode Optional Optional Consent: Please confirm that the person with parental responsibility (or the young person if they are aged 16+) consent to you sharing information with the Emotional Wellbeing Hub* Yes No Details of the child or young personName* Please select…MissMr.Mrs.Ms.Mx. Title First Last Date of Birth* Day Month Year How does the young person identify their gender? Optional OptionalFemaleMaleOtherPrefer not to answerIf you selected ‘Other’, please tell us how you describe your gender identity*Ethnicity Optional 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 Optional OptionalMobile Phone Optional OptionalAddress Address Line 1 Optional Optional Address Line 2 Optional Optional City Optional Optional Postcode Optional Optional School or educational placement Optional OptionalName of Registered GP Optional OptionalRegistered GP Practice Optional OptionalNHS Number (if known) Optional Optional Emotional wellbeingPresenting Problem: Who is worried about the young person’s wellbeing at the moment and what are the main concerns? Optional OptionalHistory (including medical history): How long has this problem been around? What has happened in the past that contributes to the concern? Optional OptionalWhat is the impact of the problem on the child or young person’s daily functioning? Optional OptionalHow are things going at school (or at work), at home in the family and with friends? Optional OptionalPlease describe any complicating factors that make the problem(s) harder to deal with. Optional OptionalWhat is working well? What strengths or resources are available to this young person and their family or network? Optional OptionalWhat do you think needs to happen next to address your concerns? Optional Optional SafetyOn a scale from 0 to 10, how safe is this young person at the moment? Optional OptionalPlease select…0 – I feel unsafe12345678910 – I feel safeSummary of the risk: What are you worried will happen if nothing changes? Optional OptionalRisk history: What harm has already happened? (Please give dates and details) Optional OptionalProtective Factors: Who or what supports safety at the moment? What prevented you from scoring any lower on the scale? Optional OptionalNext step: What needs to happen to move your rating one point higher up the scale? Optional Optional GoalsIn coming to this service, what would you like to be different or what are the main goals you want to get to? Please answer these questions from your own point of view (as a concerned adult) about what you would like to see change.What is your first goal? Optional OptionalHow close are you to reaching your first goal today? Optional OptionalPlease select…0 – Goal not met at all12345 – Halfway to reaching this goal678910 – Goal reachedWhat is your second goal? Optional OptionalHow close are you to reaching your second goal today? Optional OptionalPlease select…0 – Goal not met at all12345 – Halfway to reaching this goal678910 – Goal reachedWhat is your third goal? Optional OptionalHow close are you to reaching your third goal today? Optional OptionalPlease select…0 – Goal not met at all12345 – Halfway to reaching this goal678910 – Goal reached Famlily networkContact details for family members and other important connected people (please include at least one person with parental responsibility)Please enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: Optional OptionalPlease enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: Optional OptionalPlease enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: Optional OptionalPlease enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: Optional OptionalPlease enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: Optional OptionalPlease enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: Optional Optional Other services currently or previously involvedPlease enter the service’s details including the name of the service, the keyworker’s name, their phone number, postal address and when the young person last had contact with this service Optional OptionalPlease enter the service’s details including the name of the service, the keyworker’s name, their phone number, postal address and when the young person last had contact with this service Optional OptionalPlease enter the service’s details including the name of the service, the keyworker’s name, their phone number, postal address and when the young person last had contact with this service Optional OptionalPlease enter the service’s details including the name of the service, the keyworker’s name, their phone number, postal address and when the young person last had contact with this service Optional OptionalAnything else? Optional Optional Check your answers{all_fields} This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.