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Barnet 17-25 Mental Health Support Services
Brent Young People Thrive Referral Form
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Brent Young People Thrive Referral Form
Current
Personal Details
PHQ9
GAD7
Courses
Complete
Are you a professional or parent/carer?
Yes
No
Professional or parent/carer details
First Name
Last Name
Organisation
Phone Number
Email
Reason for referral? Please Note: this is a short term therapy service. Therefore we do not see clients with severe and enduring mental health difficulties such complex trauma)
Young Person's Details
Brent Lyra works with other organisations.
Can you confirm we can share your information with partners to ensure you receive
the best service suitable to meet your needs, by ticking the box.
Data sharing consent
Yes
No
Reason why consent withheld
First Name
Last Name
Birth Date
Street Address
Street Address Line 2
Street Address Line 3
City
Postal Code (Home)
If in education, please provide the full details of your school or college
Street Address (Place of Study/Work)
City (Place of Study/Work)
Postal Code (Place of Study/Work)
State/Province (Place of Study/Work)
- None -
Mobile Phone Number (so we can send you a SMS reminder)
Email
What service do you require?
Barnet Young People Thrive Talking Therapies
Thrive and Rise (Barnet and Enfield)
You are unsure and would like to talk to us
NHS number (Data purposes only for local need)
GP name and address (Data purposes only)
Ethnicity
Bangladeshi
Indian
Pakistani
Chinese
White-British
White-Irish
White-other
Black/Black British-African
Black/Black British-Caribbean
Black/Black British-Other
Mixed-Asian and White
Mixed-Black African and White
Mixed-Black Caribbean and White
Mixed- Any Other
Prefer not to say
Any other ethnic group
Not known
Any other Asian background
Do you speak/understand English?
Yes
No
If not, tell us what language you speak?
Would you require an interpreter?
Yes
No
Have you attempted suicide in the past? It’s very common for people to have thoughts about being better off dead or hurting themselves in some way, but often it’s because they want their distress to end, rather than wanting to end their own life)
Yes
No
If yes, please state when
What areas would you like to focus on?
Building self esteem
Confronting anxiety provoking situations
Managing difficult emotions
Other
If other, please tell us what.
Below are the conditions we work with, please select the appropriate condition
Anxiety
Emotional Dysregulation
Exam Stress
Low Mood
Phobias
Panic Attacks
Sleep Difficulties
Stress
Unhealthy Habits
Worry
Please tell us more if you can?
Onset: When did this mental/emotional health problem start?
What would you like to change in your life with therapy?
With this support what changes would make your life better?
Are you living with any long-term health conditions?
Yes
No
Are you taking any psychiatric medication?
Yes
No
If yes, please state what psychiatric medication
Have you ever experienced trauma? (For example: experiencing recurring nightmares; unwanted thoughts about an event; reexperiencing emotions associated with the traumatic event; flashbacks; feeling like the trauma is happening).
Yes
No
Prefer not to say
Do you have any additional educational needs, i.e. Dyslexia?
Yes
No
If yes, please state what
Are you registered disabled?
Yes
No
Do you identify as the gender which you were given at birth?
Yes
No
Please select how you identify.
Male
Female
Other
Prefer not to say
Are you a carer?
Yes
No
State/Province
- None -
Activity 4
Activity Date
Activity Date: Date
Activity Date: Time
Activity Date
Activity Date: Date
Activity Date: Time
Activity Date
Activity Date: Date
Activity Date: Time
Activity Date
Activity Date: Date
Activity Date: Time