Young person's MHST referral form

There are 5 sections to complete on this form.

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

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

This form may take around 15 to 20 minutes to complete.

I agree for information to be shared with other organisations *

Yes, I give permission for my information to be shared with other organisations

I agree for the MHST to view what is recorded by other care services *

Yes, I give permission for MHST to view my information recorded by other care services

Are you happy for us to share information with your parent or carer? *

Yes

If no, please tell us why *

Do your parents or carers know about this referral? *

Yes

Please select your preferred contact method *

Phone call Email Text message