Parent/Carer (for a person 0-25 years) & Professionals (for a person 18-25) referral form "*" indicates required fields Step 1 of 8 – Initial Screening 12% 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 Requires assessment for First Episode Psychosis Optional Requires assessment for Eating Disorders Optional Please give additional details if you have ticked any of the boxes above: Optional Name First Optional Last Optional Role//relationship to the young person OptionalService/team/organisation (if applicable) OptionalHome/office phone number OptionalMobile phone number OptionalEmail Enter Email Optional Confirm Email Optional Address Address Line 1 Optional Address Line 2 Optional Town Optional Postcode 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 Name* Please select…MissMr.Mrs.Ms.Mx. Title First Last Date of Birth* Day Month Year How does the young person identify their gender? OptionalFemaleMaleOtherPrefer not to answerIf you selected ‘Other’, please tell us how you describe your gender identity*Ethnicity 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 Address Line 1 Optional Address Line 2 Optional City Optional Postcode Optional School or educational placement OptionalName of Registered GP OptionalRegistered GP Practice OptionalNHS Number (if known) Optional Presenting Problem: Who is worried about the young person’s wellbeing at the moment and what are the main concerns? OptionalHistory (including medical history): How long has this problem been around? What has happened in the past that contributes to the concern? OptionalWhat is the impact of the problem on the child or young person’s daily functioning? OptionalHow are things going at school (or at work), at home in the family and with friends? OptionalPlease describe any complicating factors that make the problem(s) harder to deal with. OptionalWhat is working well? What strengths or resources are available to this young person and their family or network? OptionalWhat do you think needs to happen next to address your concerns? Optional On a scale from 0 to 10, how safe is this young person at the moment? OptionalPlease select…0 – I feel unsafe12345678910 – I feel safeSummary of the risk: What are you worried will happen if nothing changes? OptionalRisk history: What harm has already happened? (Please give dates and details) OptionalProtective Factors: Who or what supports safety at the moment? What prevented you from scoring any lower on the scale? OptionalNext step: What needs to happen to move your rating one point higher up the scale? Optional In 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? 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 Contact 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: OptionalPlease enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: OptionalPlease enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: OptionalPlease enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: OptionalPlease enter the person’s details including first name, surname, relationship to the young person, phone number, email address and postal address: OptionalPlease enter the person’s details including first name, surname, relationship to the young person, 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 the young person 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 the young person 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 the young person 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 the young person last had contact with this service OptionalAnything else? 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