英國心泉服務申請表 Application form for HK Well UK services 

本表格只供求助兒童之家長/監護人或16-18歲之求助兒童填寫。

「英國心泉」遵循專業守則，包括保密原則。即除了某幾種例外情況下，在沒有你的同意下，我們不會披露你的資料給非「英國心泉」工作人員的第三方。這些例外情況包括： 我們極度擔心你或別人遭受傷害；涉及懷疑虐待或疏忽照顧兒童；涉及刑事檢控程序等。詳見https://hongkongwell.uk/safeguarding-policy/及https://hongkongwell.uk/cic-privacy-notice/。

提交本申請即你明白並同意此安排。

如遇緊急精神健康危機或緊急情況，請電111/999 或當區NHS緊急精神健康熱線或聯絡家庭醫生作緊急會診。詳見https://www.nhs.uk/nhs-services/mental-health-services/where-to-get-urgent-help-for-mental-health/

另所收集的個人資料只會用於推廣英國心泉的活動及服務。

This application form is to be completed only by the parents of child in need or child in need aged 16-18.

Hong Kong Well UK adheres to a professional code of ethical standards which includes the principle of confidentiality.  This means that we would not disclose information about you to a third party other than members of Hong Kong Well UK without your consensus, except in situations where there is reason to suspect imminent danger of you harming yourself or someone else; or abuse or neglect of children, the elderly, or disabled persons.  Please refer to our safeguarding policy and privacy  notice at https://hongkongwell.uk/safeguarding-policy/及https://hongkongwell.uk/cic-privacy-notice/。

By submitting this application, you consent to the above.  

If you need help for a mental health crisis or emergency, you should get advice from 111/999 or NHS urgent mental health helplines or ask for an urgent GP appointment. Please refer to https://www.nhs.uk/nhs-services/mental-health-services/where-to-get-urgent-help-for-mental-health/

Your personal data will be used to inform you about information and updates relevant to Hong Kong Well UK. 
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Email *
你現居於何地區？ Where are you living?  *
請提供郵編號碼之前半部（例如ME7 1AB, 則填寫ME7 。此資料有助於工作人員在與你溝通前，先了解你居住地的支援服務，好能向你提供即時和合適的協助。） Please provide the first part of your postal code (eg. for postal code ME17 1AB, please key in ME17. This information will help our team member in better understanding supports in your area so that they can provide more speedy and appropriate advice in their discussion with you.)
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你以何種身份於英國居留？You are residing in the UK under what status?
注意：本會有機會要求你提供證明文件，以核實你申報的居留身份 You may be asked to provide proof of your migration status 
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你於何年何月遷居英國？When did you move to the UK?
(注意：非BNO 簽證持有人日後申請由本會津助之評估及輔導服務時，本會有機會要求你提供證明文件，如學校錄取你子女之通知書，以核實資格。Non BN(O) Visa holder may be asked to provide proof of your claim such as the school enrolment notice of your child/children; when you apply for our subsidised triage assessment and/or counselling services.)
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你的姓名 Your name
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你的電話號碼 Your phone number
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求助兒童的年齡 Age of the child needing help
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求助兒童的性別 Gender of the child needing help *
求助兒童的就讀年級 Class year of the child needing help
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你需要英國心泉提供哪些資訊或協助？What kind of information or services you are seeking from Hong Kong Well UK?
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求助兒童的行為/情緒問題是什麼? What's the behavioural or emotional issues of the child needing help?
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Required
求助兒童來英前後的行為/情緒表現有何差別? How has the behaviour of the child needing help changed before and after migrating to the UK?
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求助兒童現時與家人的關係如何? (包括與英國/香港家人的關係) How's the relationship of the child needing help with family member(s) including those in Hong Kong and the UK?
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求助兒童現時在英國學校適應情況如何? How well is the child needing help adapting to local schools?
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求助兒童現時的社交生活情況如何?(包括與英國/香港朋友的關係) How well is the social relationship of the child needing help including those with friends both in the UK and Hong Kong?
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家長或求助兒童曾否向學校/家庭醫生(GP)/居住地區政府部門/社會服務機構求助？Have the parent or the child needing help sought help from the school, GP, local council as well as other community services?
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若有求助，情況如何？If yes, please provide more information?
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求助兒童是否有特殊教育需要(SEN)如自閉症、學習困難等? 若有，請提供詳情。Has the child needing help any special education need? If yes please provide details.
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若你的英國電話號碼未能使用Whatsapp，請提供可用WhatsApp聯絡你的電話號碼，以方便我們聯絡你。If you have not registered your UK's phone no. for using WhatsApp, please provide another one.
資料保護
英國心泉會根據本機構之資料保密政策及私隱保護指引，處理閣下提供之資料。We will handle the information provided in accordance with our data protection policy and privacy notice. 
A copy of your responses will be emailed to the address you provided.
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