Acknowledgment - I have read the above statement
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Young person's details
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First Name
Last Name
Date of birth
*
MM
DD
YYYY
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Mobile Phone
*
(###)
###
####
Email
*
Details of person completing the form
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First Name
Last Name
Relationship to young person
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Email
*
Phone
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(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency contact (if different to above) - please give name, relationship and contact details
*
Who has parental responsibility for this young person? (e.g. Both parents)
*
Who else lives at home? Please give first name, ages, occupations and relationships to young person. Don't forget pets!
School/college (if applicable)
GP surgery
What are your main concerns about your child?
When did you first notice these problems?
What has already been tried? (Please give dates, e.g. 2021 - 6 sessions of CBT)
What are your child's main strengths and interests?
How is your child doing in school?
How would you describe your child's relationships with peers?
Are you aware of any thoughts or actions indicating that your child may be a risk to themselves or others? This would include suicidal thoughts or acts, deliberate self harm such as cutting, and aggressive words or actions, or social media concerns
Do you have concerns about how your child eats, sleeps, or other aspects of self care?
What are your hopes for any treatment your child may receive?
Personal history
What was your child's birth like? And how would you describe the first two years of their life?
Please give a brief timeline of important events in your child's life. Give details of any losses, transitions, separations, serious illness and injuries, achievements and upsets.
Does anyone else in the family have a history of mental health problems?
Is there anything else you think it would be helpful for me to be aware of?
