Page 1 of 1
RefType
A
Melo Self Referral
*
B
Melo Professional Referral
Children or Young Person Details
*
*
*
*
*
If child is 16 or older, please provide their email
Address
*
*
*
*
*
*
Parent/Carer Contact Details (if under 18) / Emergency contact details
*
*
*
Do not contact Parent or Carer without contacting the Child or Young Person first.
DoNotContact
Do Not Contact
SEND
*
Diagnosed
*
Demographics
*
Professional Information
*
*
*
*
*
*
To enable us to keep you safe whilst you wait to enter the MELO service please provide us with the following information relating to the person who as been referred into the service:
1. For the individual referred is there a history or current concern relating to Self-Harm/Self Injury
*
SR_Q1_YN
A
Yes
B
No
2. For the individual referred is there a history or current concern relating Suicidal Ideation
*
SR_Q2_YN
A
Yes
B
No
3. For the individual referred is there a history or current concern relating to Harm towards others
*
SR_Q3_YN
A
Yes
B
No
4. For the individual referred is there a history or current concern relating to Risk from others/Exploitation
*
SR_Q4_YN
A
Yes
B
No
5. Has the individual referred experienced or is currently at risk of radicalisation (PREVENT)
*
SR_Q5_YN
A
Yes
B
No
6. Do you have any other concerns relating to risk factors or safeguarding?
*
SR_Q7_YN
A
Yes
B
No
7.
Are you, or is your child/young person or anyone in the household currently being supported by any statutory agencies (for example children's services, youth services, CAMHS)?
*
SR_Q8_YN
A
Yes
B
No
8. Are you or your child Care of local authority?
*
SR_Q9YN
A
Yes
B
No
9. Are you or your child Care experienced?
*
SR_Q10YN
A
Yes
B
No
10. Are you or your child a neurodivergent Child or Young person?
*
SR_Q11YN
A
Yes
B
No
11. Are you or your child a Young Carer?
*
SR_Q12YN
A
Yes
B
No
12. Have you or has your child/young person received medical attention as a result of self-harm within the last 3 months?
*
SR_Q13YN
A
Yes
B
No
13. Have you or has your child/young person recently (within last 12 months) witnessed or experienced any form of abuse?
*
SR_Q14YN
A
Yes
B
No
14. Are you or is your child/young person, living in a household where they are currently witnessing or experiencing domestic abuse?
*
SR_Q15YN
A
Yes
B
No
Reason for Referral
Please let us know why you are making this referral,including details of any previous mental health problems. In this section you might like to include some of the following: •
*
- A description of any emotional and wellbeing difficulties you/your child might be having. - How long have these been affecting you/your child? - What impact have these had on you/your child,and have it had any impact on your family, school/work, or friends? - Have there been any big family events or illnesses recently? - Any other information? (The more information you include, the better we can decide on how best to support you or your child).
Data Protection, Information Sharing
What information do you hold about me? For us to provide you with a service we need to record some of your personal information. This can include: your name, address, telephone numbers, date of birth, email address, ethnicity, or any vulnerabilities.
I consent to ONSIDE storing and using the personal information I have provided and understand how ONSIDE will use personal data and my rights:
*
Consent
Yes
*
*
Do you want a copy of this data sent to your email?
Do you want a copy of this data sent to your email?
A
Yes
B
No
What we do with your information and who we share it with: • Your provided information remains confidential and will only be shared with those directly involved in your support. • We may also use general statistical information about you (that has been anonymised) to report back to the Department of Health and Social Care and for internal monitoring purposes. • We will not disclose your information to any other third parties without your permission, unless there is a legal requirement to share the information or if there is a safeguarding concern. In these cases, we are required by law to share information with the relevant local authority. We can do this without your consent; however we will always endeavour to inform you beforehand. Your rights You have the following rights under data protection legislation: • To know what information ONSIDE holds about you ('right to be informed'). • To request access to or a copy of the information ONSIDE holds about you ('right of access'). • To have your data corrected if it is inaccurate ('right to rectification'). • To have your data erased where ONSIDE does not have an overriding legal obligation or reason to retain it ('right to erasure'). • To prevent your data being used, if you have contested and are pending resolution in relation to its lawful use, accuracy, or impact of your rights, or require that it is retained in relation to a legal claim (‘right to restriction of processing’). • To object to its use, including opting out of receiving marketing such as our newsletter (‘right to object’). • To request that we pass data about yourself, that you provided us, to another organisation on your behalf (‘right to data portability’). How long we hold your information and how you can access it: Your information will be held securely for 7 years as required by contract, after which it will be safely destroyed. During this time, you have the right to request a copy of any personal information we hold about you. Should you wish to obtain a copy, please contact our administration team for further information. Onside ensures that they will comply with all legislation relating to the collection and retention of data including but not limited to the Data Protection Act 1998. Our guiding principle is that we are holding your records in strictest confidence. You may withdraw your consent at any time. For further information please contact our administration team. As part of this project, ONSIDE may support you into other services. This may be access to further mental health support, housing support or access to counselling. If you do not want us to share information with external organisation, please let your worker know who will update our records.
Submit
