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Parent/Carer Consultation Request
If you are a parent/carer and would like some advice and guidance for your child/young person who is experiencing low to medium mental health concerns. Please complete our consultation request below.
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* Indicates required question
Email
*
Your email
Your Name
*
Your answer
Phone number
*
Your answer
What is your full address including postcode?
*
Your answer
What is your main language?
*
Your answer
Do you consent to us storing and processing your information on our system?
(Please note we need consent to enable you to partake in the consultation)
*
Yes
No
What is your relationship with your child/young person?
(Please select from the list below)
*
Mother
Father
Grandparent
Auntie
Uncle
Other relative
Carer including foster and adoption
Other
Please tell us what school/college your child/young person attends:
*
Choose
Academy at Worden
Albany Academy
All Hallows Catholic High School
Archbishop Temple School
Ashton Community Science College
Balshaws High School
Bishop Martin Church of England
Bishop Rawstorne Church of England Academy
Brookfield Park Primary School
Broughton High School
Brownedge St Mary's RC High School
Cardinal Newman College
Christ the King Catholic High School
Cobbs Brow School
Corpus Christi Catholic High School
Crawford Village Primary School
Crow Orchard Primary School
Delph Side Community Primary School
Eden Boys School
Elm Tree Community Primary School
Fulwood Academy
Hillside Community Primary School
Holland Moor Primary School
Holy Cross High School
Hope High School
Hutton Grammer School
Larches PRU
Lathom High School
Leyland St Marys High School
Little Digmoor Primary School
Longridge High School
Lostock Hall Academy
Moor Brook School
Moor Park High School and Sixth Form
Moorside Community Primary Academy
Myrescough College
Our Lady Queen of Peace Catholic Engineering College
Our Lady's Catholic High School
Parklands Academy
Penwortham Girls High School
Penwortham Priory High School
Preston College
Preston Muslim Girls
Runshaw College
Sir Tom Finney Community High School
Southlands High School
St Cecilia's High School
St. Edmund's Catholic Primary School
St Francis of Assi Catholic Primary School
St James' Catholic Primary School
St John's Catholic Primary School
St Michaels High School
St Richards Catholic Primary School
St Teresa's Catholic Primary School
St Thomas The Martyr CE Primary School
Trinity Church of England/Methodist Primary School
Up Hollands High School
Upholland Roby Mill C of E
Walton-le-Dale High School
Wellfield High School
West Lancashire Community High School
West Lancs College
Woodland Primary School
What year group is your child/young person?
(Please select from the list below)
*
Reception
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Year 13
Other
How old is your child/young person in?
(Please select from the list below)
*
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
What is your child's Date of Birth?
*
MM
/
DD
/
YYYY
What is the Ethnicity of your child/young person?
(Please select from the list below)
*
White British
White Irish
Any other white background
Mixed White and Black Caribbean
Mixed White and Black African
Any other Mixed Background
Asian or Asian British – Indian
Asian or Asian British – Pakistani
Asian or Asian British – Bangladeshi
Any other Asian Background
Black or Black British – Caribbean
Black or Black British – African
Black or Black British – Other
Other Ethnic group – Chinese
Other
What is child/young persons full name?
*
Your answer
What is your accommodation status with your child/young person?
(Please select from the list below)
*
Living with me (Parent/Carer)
Living with relatives
Fostered
Adopted
Indepenedant Living
Living between parents/carers
If your child/young persons address is different to yours or they live between two different addresses please add the address below:
*
Your answer
Your child/young person's main language?
*
Your answer
What is your child/young persons GP surgery?
(Please include full details, with address and postcode)
*
Your answer
Does your child/young person have any additional needs?
(Please select from the list below)
*
No Additional Needs
Child protection plan/ child in need plan/ early help (please specify)
Elected Home Educated
Looked After Child/ Special Guardianship Order/ Care Leaver
Young Carer
Excluded / at risk of
Substance Misuse
Not in Education Employment or Training
Special Educational Need or Disability (SEND)
Physical health needs (including allergies)
Education Health and Care Plan (EHCP)
Required
Preferred day/time for us to call (Our working hours are 9am-5pm - Mon-Thurs and 9am - 4.40pm Fri):
*
Your answer
What is the primary concern/issue with your child/young person:
*
Anxiety
Low Mood
Other:
We are an early-intervention service
, therefore if you have an immediate safeguarding concern please call:
Children’s Social Care out of hours on 0300 123 6722.
If you think a child is in immediate danger – don't delay call the police on 999
If you are a young person looking for further support the following services are available.
Mental Health NHS Crisis Line Lancashire and South Cumbria - Call: 0800 953 0110- 24hrs, 7 days a week.
The Lancashire NHS Wellbeing Helpline & Texting Service that can offer emotional support and signposting.
Telephone: 0800 915 4640 or text ‘Hello’ to 07860 022846 7pm – 11pm Monday -Friday, 12pm – 12am Saturday and Sunday.
HOPELINEUK- Call: 0800 0684141 Text: 07860 039967 Email:
pat@papyrus-uk.org
Childline -
https://www.childline.org.uk/get-support/contacting-childline/
YoungMinds Crisis Messenger text service provides free, 24/7 crisis support across the UK, text YM to 85258
https://www.youngminds.org.uk
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