Toolbox Therapy
Initial Referral Form
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Email *
Name (Young Person) *
Preferred Name (Young Person) *
Pronouns (Young Person) *
Date of Birth (Young Person) *
MM
/
DD
/
YYYY
Age *
Address (Young Person) *
Postcode (Young Person) *
Contact Number  *
What School, if any, does the Young Person attend? *
Name (Parent/Carer) *
Pronouns (Parent/Carer)
Address (Parent/Carer) *
Contact Telephone Number (Parent/Carer) *
Email Address (Parent/Carer) *
Is the young person aware of this referral? *
If not Parent/Carer, who is making this referral and in what capacity do you know the young person?
Service / Agency (if appropriate)
Contact Details:
Reasons for referring Young Person for Therapy? *
How long have you been experiencing difficulties with your Mental Health? *
Have you attended A&E recently due to Mental Health difficulties? *
Have you seen your GP recently due to Mental Health difficulties? *
Are there currently any other services involved with your family? *
Please note access to the information on this form is limited to those professionals involved the therapy project. We will follow GDPR and all forms will be saved to a secure drive in line with data protection. Please sign and date below to indicate you give permission for us to store your personal data in this way. *
What Happens Next?
- We will process and review this referral form against our criteria. 
- We aim to respond to referrals within 2 weeks.
- We will either send you an appointment for an Initial Assessment, or if our service is not appropriate, we will signpost you to other services / agencies that can better meet your needs. 

If you have any questions please do not hesitate to contact us on toolboxtherapy@stbbc.org.uk
A copy of your responses will be emailed to the address you provided.
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