Parent or carer MHST referral form

There are 5 sections to complete on this form.

In sections 1 to 4 we ask for information about consent and contact details.

In section 5 you can tell us about the reason for making this referral.

This form may take around 10 to 20 minutes to complete.

Sometimes, when people feel sad or worried, they might have thoughts about hurting themselves. You can still make a referral to our service if your child is having these thoughts, but only if they do not have any plans to act on them.

I confirm I have parental responsibility for this child (you have legal authority to make key decisions regarding their care and welfare before they turn 18 years old)

I confirm my child is not planning to act on their thoughts of self-harm

I confirm my child is not thinking about attempting to end their life

If your child does have plans to hurt themselves and you feel that you or they can’t keep themselves safe, it’s very important to get help straight away.

You can:

contact First Response Service by calling 111 and selecting the mental health option
attend an A&E department

If your child does have plans to hurt themselves but there are no concerns about their immediate safety, you can make a referral to YOUnited. Please be aware your referral may not be reviewed by YOUnited immediately.

MHST does not provide an emergency response or crisis support.

I confirm I understand the above to proceed with the self-referral form

I understand that if MHST does not cover my child's school, the referral will be sent directly to YOUnited

Cambridgeshire and Peterborough

Cambridgeshire

Peterborough

Parent or carer MHST referral form

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