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Home » What we offer » Young People Services » Young People Groups » Connected Minds » Connected Minds Referral Form

Young People Groups

Connected Minds Referral Form

The primary aim of the 9-week Connected Minds programme is to support 10-13-year-olds (Year 6–8) with mild to moderate anxiety and emotional problems and/or experiencing low attendances at school.

We rely on the information you provide to inform us of the needs of the young person you are wishing to refer, so please ensure you have provided us with up-to-date information, notifying us of any risks we need to be aware of.

Please ensure that the young person is present whilst completing this form as they are needed to complete the Strength and difficulties questionnaire (SDQ) before the form is submitted.

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1Your Details

2Service Needs

3Contacts

4Marketing Consent

5Strengths & Difficulties Questionnaire

Referrer Information

Name of referrer

First

Last

Organisation name

Referrer phone number

Referrer email

Participant information

Name *

First

Last

Date of birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Phone *

Gender *

Ethnicity

School/Educational provider name *

School year group *

GP practice name *

Does the young person have any allergies/ intolerances?

Please briefly describe the young person’s current situation and how they might benefit from the Connected Minds service. *

Please tell us a little about any issues the young person has around attending school (if any). *

Please tell us what the young person’s level of engagement is when they are in school (if any). *

Please tell us about any issues the young person has surrounding behaviour (if any). *

Please tell us about any issues the young person has surrounding self-esteem and confidence (if any). *

Please describe how much formal and informal support this young person receives. Please provide more information about the nature and possible risks or needs associated (E.G do they have help at school or are they waiting for CAMHS support) *

Does this young person have any physical health issues, disabilities, sensory or mobility impairments? *

Does this young person have a mental health/neurodiverse diagnosis? *

Please provide details

Please provide any additional information about the young person that may be useful below.

Parent/carer/guardian details

Name

First

Last

Relationship to participant

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Is the parent/carer/guardian the young person’s emergency contact?

If no, please note the name of the emergency contact, their relationship with the young person and their contact phone number below

Consent

Has the young person consented to this referral?

Are Parents/Carers/Guardians aware of this referral and has consent been given to attend the programme?

Personal Information

Your personal information is requested for the following reasons:

to contact you about changes or cancellations to sessions days or times
to inform you of other relevant events and to be able to identify you to another agency in the event of an emergency (e.g., your GP, Community Mental Health Service, Emergency Services).

All the identifiable information you provide is kept in the strictest confidence according to the General Data Protection Regulations 2018. Any information used for statistical analysis is anonymised and will not identify you personally.

GP contact information

There are circumstances in which we may have to disclose information about you or information that you have shared with us to a third party in accordance with the Care Act 2014. For example, if you share something which means that you, a vulnerable person (an adult, child, or young person under 18) or members of the public may be at risk of significant harm we would need to contact the relevant emergency services. If you are at risk of significant harm, we may need to contact your GP, CAMHS/Community Mental Health Team or another emergency service. If we need to disclose information about you to a third party, we will discuss with you who we need to contact and why. The reasons we may do this are set out in our Privacy notice, along with how you can access any information that we hold about you. This privacy notice can be viewed:

https://dorsetmind.uk/privacy-policy/ or you can request a copy by emailing dmyh@dorsetmind.uk.

Dorset Mind Communications

Please fill out the below section if you are a PARENT/CARER for a young person and would like to receive communications from Dorset Mind. We would like to share news, campaigns, events, and opportunities at Dorset Mind with you.

You can find about your how we use your information, including rights and choices, in Dorset Minds Privacy Policy.

Checkboxes

Please tick this box to enable the marketing team to contact you with relevant information that might be of interest.

You have the right to opt-out of marketing communications at any time. To opt-out please contact datasecurity@dorsetmind.uk.

Strengths & Difficulties Questionnaire

Before we process the referral, it is extremely important that the young person completes the Strengths and Difficulties Questionnaire (SDQ) themselves on the page below. This gives us some important insight into their individual needs and ensures that this programme is suitable for them. Please note that without a completed SDQ we will not be able to progress the referral process.

We are also happy to take referrals via email: connectedminds@dorsetmind.uk

For each item, select from the dropdown whether it is Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not certain, or the item seems daft!

Please give your answers based on how things have been for you over the last six months;

I try to be nice to other people. I care about their feelings

I am restless, I cannot stay still for long

I get a lot of headaches, stomach-aches, or sickness

I usually share with others (food, games, pens etc.)

I get very angry and often lose my temper

I am usually on my own. I generally play alone or keep to myself

I usually do as I am told

I worry a lot

I am helpful if someone is hurt, upset or feeling ill

I am constantly fidgeting or squirming

I have one good friend or more

I fight a lot. I can make other people do what I want

I am often unhappy, downhearted, or tearful

Other people my age generally like me

I am easily distracted; I find it difficult to concentrate

I am nervous in new situations. I easily lose confidence

I am kind to younger children

I am often accused of lying or cheating

Other children or young people pick on me or bully me

I often volunteer to help others (parents, teachers, children)

I think before I do things

I take things that are not mine from home, school or elsewhere

I get on better with adults than with people my own age

I have many fears, I am easily scared

I finish the work I'm doing. My attention is good

Name *

First

Last

Date *

Signed *

GDPR Agreement *

I consent to Dorset Mind storing and processing my application in line with their policies and procedures and in line with the Data Protection Legislation

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Terms and conditions
Accessibility
Privacy Policy
Gender Equality Plan
Press Enquiries
Contact

Web design by Crowd Development by Dorset Tech