Fields marked * are required.
Fields marked ** are required when further information is needed to support the preceding question.
Consent
Myself    Someone else
Yes I am under the age of 16    No I am over the age of 16
Yes   No
Yes   No
Yes   No

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Yes   No
Yes   No

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My Details

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Your email will be added to the NHS record and you may be contacted by other NHS services

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Enter Preferred Contact Method, more than one can be selected.

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Yes   No   Don't Know

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Child/Young Person Details

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Your email will be added to the NHS record and you may be contacted by other NHS services

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Enter Preferred Contact Method, more than one can be selected.

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Yes   No   Don't Know

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Child/Young Person Details

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Your email will be added to the NHS record and you may be contacted by other NHS services

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Enter Preferred Contact Method, more than one can be selected.

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Yes   No   Don't Know

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Referrer Details

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Your Parent / Carer's Details

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Parent / Carer's Details

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Referrer / Contact Details

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Your Other Agencies Involved
Yes    No
Yes    No
Yes    No

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Yes    No
Yes    No
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Yes    No

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Young Person's Other Agencies Involved
Yes    No
Yes    No
Yes    No

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Yes    No
Yes    No
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Yes    No

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Other Agencies Involved with Young Person
Yes    No
Yes    No
Yes    No

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Yes    No
Yes    No
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Yes    No

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What's happening for you?
• Please describe what you have experienced?
• What may have led to your current concerns?
• What strategies or interventions have helped?
• Are there existing diagnoses (e.g. Dyslexia, medical diagnosis, Learning Disability, ASD, Autism, ADHD)?
• Highlight any risks you are aware of?

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(E.g. attendance / learning / concentration) and on hobbies, activities, interests, and relationships with others.
• Are you attending school or home schooled?
• Do you have any extra help for learning? Is there a TAF (Team around the family meeting), One Plan or Education Health Care (EHC) Plan in place?
• Is a One Plan or TAF being considered or named on the SEN register?
• Please specify what your extra help consists of.

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Please include what goes well at home and with your family.
Who lives at home?
A brief summary of your family life / family relationships
Please include any impact on your family life.
Please include the health of parents and siblings if this is causing you concern

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Description of current situation
(e.g. anxiety, low mood, emotional and behavioural difficulties, hearing voices, eating disorder, using drugs and alcohol, self-harm, suicidal ideation, harm to others etc)?
• Please describe what you have experienced or observed?
• What may have led to the current concerns?
• What strategies or interventions have helped?
• Are there existing diagnoses (e.g. Dyslexia, medical diagnosis, Learning Disability, ASD, Autism, ADHD)?
• Highlight any risks you are aware of?

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(E.g. attendance / learning / concentration) and on hobbies, activities, interests, and relationships with others.
• Is your young person attending school or home schooled? Please provide full details.
• Do they have extra help for learning? Is there a TAF (Team around the family meeting), One Plan or Education Health Care (EHC) Plan in place?
• Is a One Plan or TAF being considered or named on the SEN register?
• Please specify what the extra help consists of.

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Please include what goes well at home and with your family.
Who lives at home?
A brief summary of family life / family relationships / parenting concerns.
Please include impact on family life.
Please include the health family members if this is felt to be significant.

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Description of current situation
(e.g. anxiety, low mood, emotional and behavioural difficulties, hearing voices, eating disorder, using drugs and alcohol, self-harm, suicidal ideation, harm to others etc)?
• Please describe what you have experienced or observed?
• What may have led to the current concerns?
• What strategies or interventions have helped?
• Are there existing diagnoses (e.g. Dyslexia, medical diagnosis, Learning Disability, ASD, Autism, ADHD)?
• Highlight any risks you are aware of?

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(E.g. attendance / learning / concentration) and on hobbies, activities, interests, and relationships with others.
• Is the child attending school or home schooled? Please provide full details.
• Is their extra help for learning? Is there a TAF (Team around the family meeting), One Plan or Education Health Care (EHC) Plan in place?
• Is a One Plan or TAF being considered or named on the SEN register?
• Please specify what the extra help consists of.

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Please include what goes well at home and with the family.
Who lives at home?
A brief summary of family life / family relationships / parenting.
Please include impact on family life.
Please include the health of parents and siblings if this is felt to be significant.

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Description of current situation
Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Yes   No   Not sure
Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.

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Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.

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Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Yes ECG   Yes Blood Test   No
Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.

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Description of current situation
Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI
Yes   No   Not sure
Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI

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Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI

characters remaining

Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI

characters remaining

Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI
Yes ECG   Yes Blood Test   No
Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI

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Description of current situation
Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI
Yes   No   Not sure
Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI

characters remaining

Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI

characters remaining

Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI

characters remaining

Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI
Yes ECG   Yes Blood Test   No
Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI

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Description of current situation
Yes   No
Severe   Profound

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Yes   No

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Description of current situation
Yes   No
Severe   Profound

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Yes   No

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Further information for this online referral form can be found here. This needs to be reviewed before making a referral.
If you would like to find out what happens to personal information held about you, please read our privacy policy for more information:
https://www.nelft.nhs.uk/download.cfm?ver=1014