Referral form | CHUMS Wellbeing Group Form

CHUMS Wellbeing Group Form

This form is to be completed by Parent / Carers and Professionals referring children and young people (CYP) interested in group support from one of the CHUMS emotional wellbeing services.

Specific referral criteria can be found on the service website.

Based on the referral information:

- This referral may lead to an assessment for one of the CHUMS “getting help” therapeutic groups.

- We will provide signposting and update referrers if CHUMS support is not considered appropriate for the CYP. If the CYP’s school has a mental health in schools’ team (MHST) we may directly signpost you to them.

The information below helps us understand your needs and support our reporting to evidence the work of the service. Please answer all questions as fully as possible.

Groups we offer:

Managing anxiety to reach your goal
Neurodiversity and Me
Promoting Self Esteem
Teenage Emotional Skills Group
School based anxiety – only accessible with a referral from and liaison with school

There may be other groups available in your area – please check the service website for details.

IF YOU ARE BASED IN MK AND WOULD LIKE 1:1 SUPPORT DO NOT COMPLETE THIS FORM. INSTEAD, PLEASE:

- Attend your local family centre in the first instance, who can discuss your needs

- Or for URGENT / EMERGENCY referrals make a CAMHS SPA referral

For more information please email: info@chums.uk.com.

Please use the print option from your browser, if you wish to keep a record of this referral

* Indicates a required field

I am a:

Service*

Where did you hear about CHUMS?

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Has the CYP (aged 11+) or parent/carer agreed to this referral?*

Yes

Details of the CYP being referred

CYP's First Name*

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CYP's Surname*

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Date of Birth*

Parent / Carer first and last names *

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Parent / Carer relationship to child*

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Email address:*

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Telephone number*

We will contact you via SMS text message to provide therapy appointments and reminders. Do you agree for us to contact you in this way?*

Yes

Please indicate if we may leave a message on your preferred number*

Yes

Address Line 1*

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Address Line 2

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Address Line 3

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Town/City*

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Post Code*

Name of anyone else.
- Please note it is the responsibility of the parent/carer making this referral to inform any other adults with parental responsibility about their CYP care.

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We can send letters etc on your behalf if you let us know.

Their address

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Their contact number

Relationship to child

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GP Surgery*

Current school*

CYP Gender at Birth*

Is the CYP gender currently the same as at birth?*

CYP Sexuality*

CYP Ethnic origin*

Main Language (If English is not your first language and you require additional support, please discuss this with us)

Does the CYP have any disabilites or physical restrictions*

If yes, please provide details.

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Is the CYP awaiting an ADHD assessment or self-identify as having ADHD?*

Does the CYP have a formal diagnosis of ADHD?*

Is the CYP awaiting an ASC assessment or self-identify as having autism?*

Does the CYP have a formal diagnosis of ASC?*

What other services are involved with the CYP for their current support needs *

If selected other - please specify

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Is consent given to contact other organisations? *

Yes

Please give details*

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Professional referrer details (to be completed by professionals only)

Name of Referrer

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Job Title of Referrer

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Address of Referrer

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Contact Number of Referrer

Referrer email

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Best time to contact

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Has consent been provided by the family / CYP for this referral?*

If no, please seek consent before making this referral

I accept terms and conditions. *

I would like to receive a confirmation of the referral to the email address I specified above. Please check the spam folders within your email if you do not receive a confirmation in your inbox.

Please note that CHUMS is not an Emergency Service and is not able to respond to this form urgently. Therefore, if there are any immediate risks identified or emergency care required please seek immediate advice from your GP/A&E.

Contact Email: info@chums.uk.com

Contact Telephone: 01525 863924