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? *
Please provide details
Please provide any additional information about the young person that may be useful below.
I try to be nice to other people. I care about their feelings Not true Somewhat true Certainly true
I am restless, I cannot stay still for long Not true Somewhat true Certainly true
I get a lot of headaches, stomach-aches, or sickness Not true Somewhat true Certainly true
I usually share with others (food, games, pens etc.) Not true Somewhat true Certainly true
I get very angry and often lose my temper Not true Somewhat true Certainly true
I am usually on my own. I generally play alone or keep to myself Not true Somewhat true Certainly true
I usually do as I am told Not true Somewhat true Certainly true
I worry a lot Not true Somewhat true Certainly true
I am helpful if someone is hurt, upset or feeling ill Not true Somewhat true Certainly true
I am constantly fidgeting or squirming Not true Somewhat true Certainly true
I have one good friend or more Not true Somewhat true Certainly true
I fight a lot. I can make other people do what I want Not true Somewhat true Certainly true
I am often unhappy, downhearted, or tearful Not true Somewhat true Certainly true
Other people my age generally like me Not true Somewhat true Certainly true
I am easily distracted; I find it difficult to concentrate Not true Somewhat true Certainly true
I am nervous in new situations. I easily lose confidence Not true Somewhat true Certainly true
I am kind to younger children Not true Somewhat true Certainly true
I am often accused of lying or cheating Not true Somewhat true Certainly true
Other children or young people pick on me or bully me Not true Somewhat true Certainly true
I often volunteer to help others (parents, teachers, children) Not true Somewhat true Certainly true
I think before I do things Not true Somewhat true Certainly true
I take things that are not mine from home, school or elsewhere Not true Somewhat true Certainly true
I get on better with adults than with people my own age Not true Somewhat true Certainly true
I have many fears, I am easily scared Not true Somewhat true Certainly true
I finish the work I'm doing. My attention is good Not true Somewhat true Certainly true
Signed *
