Circle Referral Form 2.0

  • Circle Referral Form

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  • The Circle is a safe space, providing mental health support to children and young people aged 5-18 who are finding it hard to cope. Our team is here when you need us the most and will listen without judgement.

    Please fill out the form below, and a member of our team will get back to you as soon as possible, during our opening hours.

    The Circle is open 365 days a year:

    Mon – Fri: 14:00-22:00 (drop in: 14:30-18:00, appointments: 18:00-21:00)
    Weekends and Holidays: 12:00-20:00 (drop in: 12:30-16:00, appointments: 16:00-19:00)

    If you would like to discuss anything prior to submitting a referral, then please just call on: 0203 475 0060 or email us at: circleteam@hfehmind.org.uk. Phone calls and emails will only be responded to during our opening hours.

    Alternatively, you're welcome to visit us during our drop-in hours at 44-46 South Ealing Road, W5 4QA. 

    If you or a young person you support are in need of urgent medical treatment, or feel that you are in imminent danger, please contact emergency services on 999 or attend A&E.

  • Referrer Details:

  • Format: 00000000000.
  • Is the child/young person aware of this referral?*
  • Have you attended the Circle before?*
  • Has your child attended the Circle before?*
  • Has the child/young person attended the Circle before?*
  • DOB:
     - -

  • Child/Young Person Details:

  • Date of birth:*
     - -
  • Format: 00000000000.
  • Whose number is this?*

  • Child/Young Person Details:

  • Is there an Education, Health and Care plan (EHCP) in place?
  • Do you have any special educational needs or disabilities (SEND)?
  • Does your child have any special educational needs or disabilities (SEND)?
  • Does the child/young person have any special educational needs or disabilities (SEND)?
  • Is there a child protection plan in place?
  • Are you a Looked After Child? (A child who has been in the care of their local authority for more than 24 hours is known as a Looked After Child. Looked after children are also often referred to as children in care).
  • Is your child a Looked After Child? (A child who has been in the care of their local authority for more than 24 hours is known as a Looked After Child. Looked after children are also often referred to as children in care).
  • Is the child/young person a Looked After Child? (A child who has been in the care of their local authority for more than 24 hours is known as a Looked After Child. Looked after children are also often referred to as children in care).

  • Child/Young Person's Demographics:

  • Interpreter required:*
  • Understands written English:*

  • Details of Main Parent/Carer:

    We will use these details as an emergency contact.
  • Are the details of the main parent/carer different to those of the referrer?*
  • Format: 00000000000.
  • Interpreter required:*
  • Parent/carer understands written English:*
  • Would you like to add details of an additonal parent/carer?*
  • Format: 00000000000.

  • Other Professionals:

  • Are any other agencies or professionals working with you (e.g Early Help, Social Worker)?*
  • Are any other agencies or professionals working with your child (e.g Early Help, CAMHS, Social Worker)?*
  • Are any other agencies or professionals working with this child/young person (e.g Early Help, CAMHS, Social Worker)?*

  • Current Situation:

  • I feel hopeless or like life is not worth living:*
  • My child feels hopeless or like life is not worth living:*
  • The child/young person feels hopeless or like life is not worth living:*
  • I feel that I am a danger to myself:*
  • I feel that my child is a danger to themselves:*
  • I feel that the child/young person is a danger to themselves:*
  • I feel that I am a danger to others:*
  • I feel that my child is a danger to others:*
  • I feel that the child/young person is a danger to others:*
  • I feel that I am at risk of harm from others:*
  • I feel that my child is at risk of harm from others:*
  • I feel that the child/young person is at risk of harm from others:*
  • I have made plans to end my life:*
  • My child has made plans to end their life:*
  • The child/young person has made plans to end their life:*

  • Current Situation:

  • If you hadn't used this service today would you have used A&E?*
  • Have you used A&E before for mental health support?*
  • Has the child/young person used A&E before for mental health support?*
  • Do you have a current mental health diagnosis?*
  • Does your child have a current mental health diagnosis?*
  • Does the child/young person have a current mental health diagnosis?*
  • Is there any professional mental health support in place at the moment (e.g. CAMHS, School Counsellor, Educational Psychologist)?*
  • Are you currently on a waiting list for a Mental Health Assessment (e.g. CAMHS)?*
  • Is your child currently on a waiting list for a Mental Health Assessment (e.g. CAMHS)?*
  • Is the child/young person currently on a waiting list for a Mental Health Assessment (e.g. CAMHS)?*

  • Consent:

  • Please select who will be completing the consent forms below:*
  • We offer support for parents across the organisation, including coffee mornings and workshops. Would you like to be contacted about these? (You can withdraw your consent at any point).*
  • We offer opportunities to children and young people to participate in developing our services. May we contact you (child/young person) about these opportunities? (consent can be withdrawn at any point.):*

  • Data Processing & Sharing Consent

    HFEH Mind provides emotional wellbeing and support for children and young people aged 5 – 18. 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.

  • Please ensure the boxes below are ticked to proivde data processing and sharing consent:*
  • Date:*
     - -

  • Supporting Documents:

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