Connected Minds Referral Form

Name *

First

Last

Date of birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Phone *

Gender *

School/Educational provider name *

GP practice name *

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). *

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

Does this young person have a mental health diagnosis? Yes / No *

Yes
No

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

Email

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

Yes
No

If this form has been completed by a school, GP or other organisation please provide details:

Name of referrer

First

Last

Organisation

Phone

Email

Consent

Has the young person consented to this referral?

Yes
No

Are Parents/Carers/Guardians aware of this referral?

Yes
No

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 [email protected].

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 [email protected].

Strengths & Difficulties Questionnaire

Before we process the referral, we ask that the young person completes the Strengths and Difficulties Questionnaire on the page below. This gives us some important insight into their individual needs and ensures that this programme is suitable for them.

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 *

Young People Groups

Connected Minds Referral Form

Parent/carer/guardian details

If this form has been completed by a school, GP or other organisation please provide details:

Consent

Personal Information

GP contact information

Dorset Mind Communications

Strengths & Difficulties Questionnaire

Connected Minds Referral
Form