Name of parent/carer with parental responsibility
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First Name
Last Name
Email
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Phone
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(###)
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Relationship to the young person
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Name of young person
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First Name
Last Name
Prefered name
Date of birth
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Current age
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Which postcode does the young person live in?
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Gender assigned at birth
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Their preferred pronouns (she/her they/them, etc.)
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Is the young person in education, employment or training? If so - please give details
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Does the young person have any specific mental health difficulties, learning disabilities or conditions? If YES, please give details.
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Does the young person have a formal diagnosis? Please give details
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Does the young person have a history of support from CAMHS? Please give details and someone we can contact to discuss:
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Has the young person had any previous experience of therapy or counselling? Please give details
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Does the young person have any communication or accessibility needs?
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Does the young person have any special interests, skills or aspirations you would like us to be aware of? Please give details:
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Does the young person have any caring responsabilities? Please give details
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Is there any activities or practices that the young person uses currently to support them through periods of difficulty?
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Anything else you would like us to be aware of?
Please indicate the total family income band (if you would like to be considered for grant and donation funded sessions). Please include any benefits.
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Under £15,000 pa
Between £15,000-£25,000 pa
Between £35,000-£45,000 pa
Over £45,000 pa
Does the young person have access to funding through social services/Early Help/Adoption Support Fund/DLA/school/pupil premium/local provider/privately paying/other?
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Does the young person have a history of being a risk to others? (e.g. aggressive behaviours, arson, fighting)
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Does the young person have any communication or accessibility needs? Please give details:
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Does the young person have a history of self-harming?
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Does the young person have current difficulties or a known history with self-neglect (not carrying out basic needs that support a healthy balanced lifestyle – not eating regular meals, not brushing teeth, not cleaning self and/or personal space etc)?
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Is the young person currently experiencing or has a known history of abuse or exploitation? (e.g. abuse, sexual assault, bullying). PLease give details
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Does the young person have current or a history of suicidal thoughts?
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Does the young person have a history of drug or alcohol abuse?
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Does the young person have a history of homelessness?
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Does the young person have a history of breakdown with significant attachment figure? (e.g. history of adoption, unhealthy relationship with mother/father/caregiver)
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Does the young person have a history of absconding from school or other educational setting, or running away from home?
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Please list 2 preferred contacts the young person is happy for us to contact in case of an emergency (names and phonenumbers)
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Does the young person give consent to this application?
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Does the parent/carer with parental responsibility give consent? (for all young people under 18)
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