Circle Referral Form (old)
  • Mental Health Support Team Referral Form

  • Circle Service Inclusion and Exclusion Criteria

    Inclusion Criteria:

    • Presentations not requiring medical or specialist Mental Health intervention. 
    • Presentations that have included the use of the Circle as part of their care/discharge plan and there is Care Coordinator involvement. 
    • Young people experiencing mental and emotional distress. 
    • Child/Young Person’s experiencing active thoughts of self-harm and not requiring medical or specialist care or intervention.
    • Child/Young Person experiencing fleeting suicidal thoughts with no active plan or intent and established protective factors. 
    • Parent/Carers requiring immediate advice and guidance to support their child with urgent mental health needs.

     

    Exclusion Criteria:

    • Significant self-harm requiring medical attention and/input from specialist CAMHS.
    • Presentations that require a full psychiatric mental health assessment or medical review.
    • Young people who have made a suicide attempt within in the last 3 months and are actively suicidal. 
    • Young people experiencing acute psychotic episodes
    • Acute presentations requiring both specialist physical and mental health intervention.
    • Extreme challenging behaviour requiring specialist support and/or police attendance including the use of the 136 suite for containment. 

     

  • Referrer's Details

  • Date of Referral*
     - -
  • Is the Young Person Aware of this referral?*
  • Has the young person attended the Circle previously?*

  • Details of the Child/Young Person

  • Date of Birth*
     - -
  • Format: 00000000000.
  • Whose number is this?*
  • Are you currently in employment?*
  • Child Protection Plan in place?*
  • Looked After Child?*
  • Is the Young Person a Child in Need? (This is a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services)*

  • If any of the following information has changed since your last visit, please add details to the box below:

    • School
    • GP
    • Home address
    • Contact details
    • Parent Contact Details / Emergency Contact

  • Child/Young Person Address Details

  • Child/Young Person Demographic Details

  • Interpreter required?
  • Young person understands Written English?
  • Is the Child a young Carer?*
  • Does the Child have a Special Educational Need or Disability (SEND)/mental health diagnosis*
  • Does the child/young person have an Education Health and Care Plan (EHCP)?*
  • Has the child/young person had a mental health intervention before (e.g.CAMHS, school counsellor, Educational Psychologist etc.)?*
  • Is the child/young person currently on a waiting list for a Mental Health Assessment (e.g. CAHMS)?*

  • Details of the Main Parent/Carer

  • Would you like to add details of an additional Parent/carer?
  • Is an Interpreter Required?*
  • Parent understands Written English?

  • GP Details

    Please provide the GP details of the young person

  • Details of Other Agencies/Professionals Involved

  • Are any Other Agencies or Professionals working with this Child/Young Person? (i.e. Early Help, CAMHS, Social worker?*
  • Would you like to add details of another agency or Professional?*

  • Referral Information

  • Reason For Referral: (Please tick all relevant boxes)*

  • Risk Assessment

    Please answer the following questions based on how you are currently feeling.
  • I feel hopeless or I feel like life is not worth living*
  • I feel that I am a danger to myself or others*
  • I feel that I am at risk of harm or danger by others*
  • I have made plans to end my life*

  • Risk Assessment

  • My child feels hopeless or like life is not worth living*
  • I feel my child is a danger to themselves or others*
  • I feel that my child is at risk of harm or danger by others*
  • My Child has made plans to end their life*

  • Risk Assessment

  • The child/young person feels hopeless or like life is not worth living*
  • I feel that the child/young person is a danger to themselves or others*
  • I feel that the child/young person is at risk of harm or danger by others*
  • The child/young person has made plans to end their life*
  • If you had not used this service today, would you have gone to A&E?*

  • Referral Consent Form

  • Please select who will be completing the consent forms below?*
  • As part of our service we monitor long term outcomes around your wellbeing journey. Are you happy for us to contact you about this over the next year?

  • Service User Participation

    We offer opportunities for parents/carers to participate in developing our services. Opportunities can include joining our Youth Panel, participating in workshops or focus groups, or getting involved in other research opportunities from partner mental health support agencies or academic institutions. We will never share your personal information with any third parties without your permission.


    Do you consent to us contacting you after you have exited our service to promote opportunities to participate in developing mental health services? You can withdraw this consent at any time

  • Service User Participation

    We offer opportunities for young people, and their parents/carers, to participate in developing our services. Opportunities can include joining our Youth Panel, participating in workshops or focus groups, or getting involved in other research opportunities from partner mental health support agencies or academic institutions. We will never share your personal information with any third parties without your permission.


    Do you consent to us contacting you after you have exited our service to promote opportunities to participate in developing mental health services? You can withdraw this consent at any time

  • *
  • *

  • Data Processing & Sharing Consent

    HFEH Mind provides emotional wellbeing and support for children and young people aged 5 – 19. To provide this service Hammersmith & Fulham, Ealing and Hounslow Mind will need to process data relating to the child/young person, and that of their parent/carer. (N.B: this person must have legal parental responsibility for the child/young person).


    In accordance with our retention policy, we will keep your data on our systems for a period of 6 years. After the 6-year retention period your data will be deleted from our database unless we have a lawful reason for continued retention.

    To provide a more joined up, effective service for you/the client, Hammersmith Fulham Ealing and Hounslow Mind may need to share your/the client’s information with other service providers. These include NHS England’s Mental Health Services Data Set. This is a national database, which collects data on all clients in England receiving emotional wellbeing and mental health services through NHS-funded interventions. Other service providers also include past, current, or new services that would benefit the client where the client requires a different service to that which is offered by Hammersmith Fulham Ealing and Hounslow Mind. We will only share your/the client’s data with consent unless we can lawfully do so without consent. Consent can be withdrawn at any time.

    If this section is not completed fully, the referral cannot be processed.

  • *

  • Verbal Consent:
    I, * received verbal consent from * on   Pick a Date*   .

  • Clear
  • Date of signature*
     / /

  • Archive (Staff records only)

  • DATA PROCESSING CONSENT


    The Circle is a crisis intervention for children and young people aged 5-18, who are in active emotional and mental health distress. To provide this service, Hammersmith, Fulham, Ealing and Hounslow Mind will need to process data relating to the child / young person, as well as their parent / carer. (N.B: this person must have legal parental responsibility for the child / young person).
    In guidance with our retention policy, we will keep your data on our systems for up to a period of 6 years unless otherwise instructed. After the 6 year retention period, your data is safely and securely erased from our database unless you instruct us not to. 


    By signing this form, you are consenting to your data being processed under this service:

  • Verbal Consent:
    I, * received verbal consent from * on   Pick a Date*   .

  • Clear
  • Date of signature*
     / /

  • Supporting Documents

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