Mental Health Support Team (MHST) referral form

Required

By making this referral for the named Child/Young Person below, I have assessed that all appropriate interventions at Universal Service Level have been attempted. I have gained the appropriate informed consent of either the Parent or the Child/Young Person who I have deemed to be Gillick Competent*.

* According to UK law, a child can give consent to be referred for treatment without parental knowledge if they are under the age of 16, as long as they are able to demonstrate sufficient maturity and intelligence to understand the nature and implications of the proposed treatment, including the risks and alternative courses of actions. Confidentiality may need to be breached if there is considered to be a risk to self or others. As many difficulties occur within the context of family life, treatment options could possibly be limited if there is not parental knowledge of referral.

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Consent to step up to CAMHS if required Required
Who has given consent to this referral? Required
Is the parent aware of the referral? Required
Previously been referred to MHST Required
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Mandatory statistical data collection

Are the parents of the referred Child/Young person ex-British armed forces? Required
Is the Child/Young Person being referred, a Looked After Child? Required
Does the Child/Young Person referred have an Allocated Social Worker? (Please provide full details below) Required
Is the Child/Young Person, a child in need? Required
Is the Child/Young Person, a child with a protection plan in place? Required
Is the Child/Young Person referred accessing support from other Agencies? Required
Is the Child/Young Person on the SEN register?
Does the Child/Young Person have an EHCP?
Does the Child/Young Person have confirmed Autistic Spectrum diagnosis?

Child/Young Person's details (please complete with as much information as possible)

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Translator/Interpreter required Required
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Current address Required

Sibling details

Details of main contact for the referral (This can be the Young Person (16+), Parent or Carer)

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Parent holds parental responsibility Required
Translator/Interpreter required Required
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Current address Required

General practitioners details (GP)

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Address

Other agency involved details

Address

School mental health lead contact (This is the nominated person in your school)

School Required
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Referrer's contact details (This is the person making the referral)

Address

Reason for referral/current mental health concern?

(e.g. phobias, panic attack, anxiety, depression, OCD, behavioural disorder, PTSD, self-harm, other)  

Please provide brief detail of presenting problem in the box below.

(Consider the following: Presenting concern, family life/circumstances, daily functioning, appetite, sleep, self-harm, suicidal ideations, any safeguarding issues, Social Services involvement, any school/college attendance issues)

Who does it affect and how? 

How bad is it according to Child/Young Person and parent/carer and referrer?

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Duration of problem Required
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Are there risks impacting the Child/Young Person’s safety relating to:

(Please consider: drugs and/or alcohol misuse, risky behaviours, weight and height, self-harm, suicidal ideation, unaccompanied minors, exploitation, neglect/abuse, radicalisation, domestic abuse)

What is the evidence/findings? Historical/current risks? Level of risk?

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Is there an agreed safety plan?