IThrive 2 – 19 years Referral Form

1. Details of the Person being Referred

The classification of ‘indeterminate’ is from the categories provided by NHS Digital. These are the categories we are required to use.
Please use a space e.g EC11 7YU

2. Parent / Carer Contact Details

3. Nature of Referral

In a short paragraph, please describe the child or young person’s emotional health issues/concerns, history of difficulties and any relevant background information.
What support would you like for your child or young person such as mentoring or one-one support.
For example, CAMHS, school counsellor, therapist, mentor, youth worker or social worker.
Please ask the child or young person what they are finding difficult and what they would like support with and add their response below (please note this must be done with child-young person themselves and not completed on their behalf).
Please tick the relevant boxes above to enable us to access the most appropriate service for the child as quickly as possible.

4. Risk

5. Details of the Referrer

Consent is given to share information with Bolton Together and wider agencies offering support for EHWB. Consent must be given before referring.
We put the child/young person (CYP) at the centre of the IThrive approach, empowering them and supporting them to make changes for themselves. To do this effectively, the CYP must understand what support they are accessing and to have agreed to participate in. Before referring, please ensure a conversation has taken place with the CYP about our services, and they have agreed to being referred. Please tick this box to confirm this has taken place. *Not applicable to the Early Years provision.