iThrive 2 – 19 years Referral Form

The iThrive Hub is commissioned by Bolton Together to deliver emotional health and wellbeing support for children and young people, aged 2-19 years (up to 25 with SEND).

Our support is an early intervention service, meaning we address issues early. We are not a crisis service.

The support we offer is short term, and goals based. We use a strength-based approach, using interventions that are best suited to a child’s wants, interests and needs. We use flexible and youth centred approaches.

The strategies and tools we provide aim to improve the child’s emotional health and wellbeing long-term.

We require consent and a conversation to have taken place with the child/young person prior to referring. This means that they understand what they are being referred to and have agreed to receiving the support. IThrive is a child/youth centred service and we therefore require involvement of the child/young person throughout the process.

Children and young people referred to the IThrive Hub must be registered with a Bolton GP.

1. Details of the Person being Referred

Date of Referral *

Preferred pronoun *

Name of Child/Young Person *

First

Last

Date of Birth *

Age group at point of referral *

2 - 5 Years
5 - 8 Years
8 - 11 Years
11-19

Gender *

The classification of ‘indeterminate’ is from the categories provided by NHS Digital. These are the categories we are required to use.

Ethnicity *

Sexuality *

Phone Number (Child and young person)

House number/name *

Street *

Town/city *

Area

County

Ward

Borough

Postcode *

Please use a space e.g EC11 7YU

Name of school the child/young person is enrolled with, or whether they are home schooled/ not attending school

Main school professional

Job role

Contact details

NHS Number

NHS Number Status *

GP *

Doctors Name *

Surgery Practice Details *

Address Line 1

City

State / Province / Region

Postal Code

How would you prefer to be contacted:

Email
Text
Telephone call

2. Parent / Carer Contact Details

Parent / Carer Names *

First

Last

Phone number (parent/carer) *

Email (parent/carer) *

Same address as the person being referred *

3. Nature of Referral

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.

Nature of Support *

What support would you like for your child or young person such as mentoring or one-one support.

Is there anything that we should be aware of? Please include any potential risks *

Is the child receiving support from any other agency? If so, please specify. *

For example, CAMHS, school counsellor, therapist, mentor, youth worker or social worker.

Please describe any access needs of the young person and any steps we can take to support them to access our services *

Is the young person on waiting list for other services and if so, what services are they waiting for? *

Has the child or young person recently finished work with another agency? If yes, what did that work consist of? *

What does the child/young person want support with? (Voice of the child) *

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).

Any other information *

Please tick the relevant boxes above to enable us to access the most appropriate service for the child as quickly as possible.

4. Risk

Is there any Safeguarding Risks *

5. Details of the Referrer

Name of person referring *

First

Last

Job Role/Relationship to the Child/Young Person *

Email of referrer *

Phone Number of referrer *

Parent / Carer Consent

Consent

Consent is given to share information with Bolton Together and wider agencies offering support for EHWB. Consent must be given before referring.

Child/Young Person Consent

Consent

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.

iThrive 2 – 19 years Referral Form

1. Details of the Person being Referred

2. Parent / Carer Contact Details

3. Nature of Referral

4. Risk

Why is this?

5. Details of the Referrer

Bolton Together

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