Referral Form - Clear Minds Therapy

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Info Hub
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Contact
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Referral Form

Referral for support

Newsletter

Section 1 - Basic details

Request Date

Person completing the referral:

First Name

Last Name

Email Address

Address Line 1

Address Line 2

Town/City

Postal Code

Relationship to Young Person

Mobile Phone Number

Home Phone Number

Parent/Carer 1 (please record details of those with parental responsibility):

First Name

Last Name

D.O.B

Relationship to Young Person

Parent/Carer 2 (please record details of those with parental responsibility):

First Name

Last Name

D.O.B

Relationship to Young Person

Child Details:

First Name

Last Name

D.O.B

Gender

Any Additional Support Needs

Any medical conditions?

Yes

No

Name of condition(s) if yes to previous question

Medication being taken/any instructions in case of emergency

Request for support

Support Type

Is family support needed as well as life coaching?

Section 2 - Agencies supporting family

Other agencies currently involved with family (Please tick and add names and numbers of professionals):

Family doctor

Children's Social care

CAHMS

Domestic Abuse Service

Speech and Language Therapy

Pediatrician

Early Help

Other

Family doctor

Name

Mobile Number

Children's Social care

Name

Mobile Number

CAHMS

Name

Mobile Number

Domestic Abuse Service

Name

Mobile Number

Speech and Language Therapy

Name

Mobile Number

Pediatrician

Name

Mobile Number

Early Help

Name

Mobile Number

Other

Name

Mobile Number

Section 3 - Request of support

What are the current presenting issues and the support you are requesting for your child?

Child's emotional wellbeing

Bullying

Worrying/Anxiety

Self esteem/self worth

School

Relationships

Social skills

Concerns/Support needed

Section 4 - Alternative Therapies

If you ticked yes to holistic therapies which would you be interested in for your child? (please note all alternative therapies are carried out by our trained holistic therapist. By ticking the boxes below you are agreeing to me sharing your contact details with them)

Reflexology

Reiki

Crystal Healing

Indian Head Massage

Section 5 - Consent

Parents/Carer has consented to referral:

Yes

Young person is aware of the referral:

Yes