Referral Form

Creative Mindset Referral Form

Date of Referral

First Name

Age

Gender

Ethnicity

School/agency contact details

Young person’s school (if different from referrer)

Young persons home address if sessions are NOT to be held at school

School telephone number

Referring school or agency

Head teacher

Class teacher

SENCO

DSL Name and contact details

Name of first aider

Any medical information to be shared including any diagnosis (if none enter N/A)

Where are sessions for the young person to be held

In School

At Home

In The Community

On SEN register

YES

On a Child in Need Plan

YES

Exclusions

YES

On a Child Protection Plan

YES

Looked After Child

YES

Risk Assessment in place

YES

Parents / Carers Names

Telephone No(s)

Email(s)

Childs position in family

Form completed by

Electronic Signature

Date

For Office Use ONLY – Referral suitable for Creative Mindset?

YES

For Office Use ONLY – Name of lead consultant – Once assigned

For Office Use ONLY – Consultants email address for contact

For Office Use ONLY – REASON FOR REFERRAL (eg behaviours, anxiety, life events, mood changes, relationships etc)

For Office Use ONLY – OBJECT OF REFERRAL(S)

For Office Use ONLY – OTHER CURRENT PROFFESSIONAL AGENCY INVOLVEMENT ((Please give names and dates of involvement and, in particular if there has been any CAMHS involvement, even if this has been a referral which was not picked up)