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Melo Referral
RefType
A
Melo Self Referral
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RefType
B
Melo Professional Referral
Children or Young Person Details
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If child is 16 or older, please provide their email
Address
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Parent/Carer Contact Details (if under 18) / Emergency contact details
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Do not contact Parent or Carer without contacting the Child or Young Person first.
Do Not Contact
Demographics
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Professional Information
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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 has been referred into the service:
1. For the individual referred is there a history or current concern relating to Self-Harm/Self Injury
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A
Yes
B
No
2. For the individual referred is there a history or current concern relating to Suicidal Ideation
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A
Yes
B
No
3. For the individual referred is there a history or current concern relating to harm towards others
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A
Yes
B
No
4. For the individual referred is there a history or current concern relating to Risk from others/Exploitation
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A
Yes
B
No
5. Has the individual referred experienced or is currently at risk of radicalisation (PREVENT)
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A
Yes
B
No
6. Do you have any other concerns relating to risk factors or safeguarding?
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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)?
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A
Yes
B
No
8. Are you or your child, care of the local authority?
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A
Yes
B
No
9. Are you or your child, care experienced?
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A
Yes
B
No
10. Are you or your child a Young Carer?
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A
Yes
B
No
11. Have you or has your child/young person received medical attention as a result of self-harm within the last 3 months?
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A
Yes
B
No
12. Have you or has your child/young person recently (within the last 12 months) witnessed or experienced any form of abuse?
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A
Yes
B
No
13. Are you or is your child/young person, living in a household where they are currently witnessing or experiencing domestic abuse?
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A
Yes
B
No
Reason for Referral
About You
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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).
How might you see Melo and Melo aND More supporting you? This will be explored at triage and assessment and the practitioners will work with you to create a personalised plan.
( select all that apply)
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Looking for ND specific advice and signposting
Looking for advice and signposting information
Looking for practical ND specific strategies for child / young person
Looking for practical ND specific strategies for parent / carer
Looking for practical NON ND specific strategies for child / young person
Looking for one to one support on a specific ND concern – up to three x 121 sessions
Looking for more focused 121 support with education or diagnostic pathways for ND CYP – up to six x 121 sessions
Looking for more focused 121 support around more complex emotional wellbeing CYP – up to six x 121 sessions
Not applicable
Which neurodevelopmental differences best describe you or your child?
(Select all that apply)
neurodevelopmental_profile
Autism
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ADHD
Learning Disability
Dyselxia
Dyspraxia (DCD)
Dyscalculia
Tourette Syndrome
Tic Disorder
Sensory Processing Differences
Fetal Alcohol Spectrum Disorder (FASD)
Social Communication Differences
Demand Avoidance Profile
Not sure
Other
Not applicable
Is this Diagnosed :
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A
Yes
B
No
C
Awaiting assessment
D
Self-identified
E
Unsure
F
Not applicable
Current Difficulties
Which areas are causing the greatest difficulty?
(select all that apply)
current_difficulties
Understanding anxiety - Melo
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Healthy Coping Mechanisms - Melo
Self esteem – Melo
Emotional awareness – Melo
Understanding my neurodivergence – Melo aND More
Self care – Melo aND More
Emotional regulation – Melo aND More
Managing transitions – Melo aND More
School attendance – Melo aND More
Organisation / executive functioning – Melo aND More
Not applicable
Do you / your child currently have:
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A
SEND Support
B
EHCP
C
EHCP assessment underway
D
No additional support
E
Unsure
F
Not applicable
Existing Support
Which services are currently involved?
(Select all that apply)
existing_support
GP
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CAMHs
Melo
WEST / MHST
Early help
Social Care
Educational Psychology
School SENDCo
Paediatrics
Speech and Language Therapy
Occupational Therapy
Community Paediatrics
Voluntary Sector
None
Are there any reasonable adjustments that would help us support you?
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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:
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Yes
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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.
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