Fields marked in red are required.
Please let us know why you are making this referral, including details of any previous or current mental health problems. The more information you include, the better we can decide on how best to help.
Please describe any mental health difficulties you might be having? For example: mood, appetite, sleep, concentration, motivation.
How long have these been affecting you?
Has anything happened recently to make you seek help at this time?
What impact have these had on you and have they had any impact on your family, school work or friends?
Have there been any big family/life events or illnesses recently?
Is there any further information that you think we should know?
Are parents/guardian aware of this referral?
Is the child or young person aware of this referral?
Consent to leave a voicemail on the numbers provided?
Has the child, young person or carer agreed to information being shared between school and/or agencies to help them receive help from the most appropriate source?