Somerset Phoenix Project: Parent/Carer request for support

Transcription

1 Send it back online: Today s date (completion of support form) Date initial enquiry received Somerset Phoenix Project: Parent/Carer request for support (Please use this form if you are a parent or carer to request support for your child) If you need help to complete this form please contact us on Please confirm that the young person consented to this request for support: Does the young person/child (over 13 years) consent to professionals in their lives being contacted? This is the first time I have been referred to the Somerset Phoenix Project Unknown YOUNG PERSONS INFORMATION: First name Surname Age Gender identified with DOB Area of Somerset you live in Disability or additional needs Ethnicity (See below for groups) Is a CP plan in place? Please indicate whether current or historic CONTACT DETAILS Address Landline Mobile HOW CAN WE CAN GET IN TOUCH WITH YOU (YOUNG PERSON) Ok to post mail to you? Ok to phone your landline? 1

2 Ok to phone mobile? Ok to text you? OK to leave a voic on your mobile? OK to you? Preferred way for us to contact you? Please state: I am a Parent / Carer and am making this request for support on behalf of a young person. My contact details are: Contact Details Name: Address line 1 Address line 2 Town Post code Telephone Mobile How We Can Get In Touch With You? (Parent/carer making a request for support) Ok to post mail to you? Ok to phone landline? Ok to phone mobile? Ok to text you? OK to leave a voic ? OK to you? Preferred way for us to contact you? Please state Is the child/young person mentioned above safe and no longer experiencing sexual abuse? Please state yes or When did the abuse stop? What was the abuse? Contact abuse involves touching activities where an abuser makes physical contact with you n-contact abuse involves nontouching activities Is the child/young person mentioned above involved with CAMH s (child and adolescents mental health team)? Please state past, current or referral to CAMH s submitted What relationship did the perpetrator of the abuse have to the child/young person? What is the current location of the perpetrator? (if known) BACKGROUND HISTORY 2

3 Is there a current court case or police investigation? Please state ne, Current or Historic BACKGROUND SUMMARY & SUPPORT NEEDED Can you tell us why you would like to come to the Phoenix project for support? It might be helpful to think about: What has been going on? How is this affecting the child/young person and yourself? What is going well? What would you like to be different? What support you have already? What has been going on: How it has affected the child/young person and yourself: What is going well for them and you at the moment? What is worrying them and you at the moment? What support have you all received: What types of support or activities are you interested in at the moment for your child? Individual therapeutic support: includes counselling one-to-one support: includes how to manage day-to-day; help with the other professionals in your life; support for the whole family Self-help information guides Support for my parents/carers; a small group for other parent/carers who have been affected by sexual abuse Does the child/young person self-injure or self-harm?, sometimes, often Prefer not to say Does the child/young person have suicidal thoughts? Prefer not to say Have they attempted suicide?, Once, in the last 6 months, more than once Prefer not to say Have they had any thoughts of suicide in the past 6 weeks that they have wanted to act upon? We need to make sure everybody is safe at the Phoenix Project. Please tell us if there is anything you think we need to know about you which might put others at risk. Are there any other issues about their mental health you would like us to know at this stage: E.g. physical health difficulties; medication prescribed by a doctor/psychiatrist; other crisis or risk 3

4 issues, a formal diagnosis from a GP or Psychiatrist? Are you getting any other support from any other professionals or services? E.g. social worker; psychiatrist; psychologist, etc. Please state yes or no: Please let us know of any particular needs we need to be aware of when we contact you or offer you an appointment? Returning the Form: WHAT HAPPENS NEXT? Please ensure all boxes are complete or we cannot process the form. Please this form using an encrypted so that your information is sent securely (if you need access to encryption please phone the Phoenix s number on and we can help you with this: Please then return the form to : somersetphoenixproject@barnardos.org.uk What happens next? Each request for support will be considered by the Phoenix Team at a Triage meeting. Triage meetings occur on the 2 nd and 4 th Wednesday of each month. If needed, we will contact you for more information. It is therefore important that this form is completed in as much detail as possible. Once the request for support has been considered at Triage a member of the Phoenix Team will contact you with the outcome Please note: the Phoenix Team operates on Monday, Tuesday & Wednesday (10am-4pm). FOR OFFICE USE ONLY FOR COMPLETION AT THE TRIAGE MEETING 4

5 Brief notes of discussion: Summary of outcome: Ethnicity Codes: White A B C British Irish Any other White background Asian or Asian British H J K L Indian Pakistani Bangladeshi Any other Asian background Other Ethnic Groups R S Z Chinese Any other ethnic group t stated 5