Please note: This form is for self-referrals by young people or their parent/carers only. Professionals should email bfwh.options4cyp@nhs.net for a copy of the professionals referral form.

Referrals, submitted by professionals using the self-referral form, will not be accepted. If you haven’t received an email or letter response from a NHS children and young people’s mental health service within two weeks, call 0800 121 7762. If your concern changes or becomes urgent, please call the Mental Health Crisis Line which is available 24 hours a day, seven days a week, by calling 0800 953 0110.

Use the form below to make a referral to our Options4CYP services which includes:

  • Children and Young People’s Primary Mental Health Service (up to age 18 years)
  • Blackpool Child Psychology Service
  • Youtherapy (11-25 years)
  • Blackpool CAMHS (up to age 18 years)

All referrals will be triaged and may be allocated to any one of these services. 

Provide as much detail as possible in this form, so we can effectively support you.

A self-referral will no longer be accepted for concerns relating to inattention, focus/concentration, hyperactivity or impulsiveness due to additional documentation which is required at the point of referral. 

Please discuss these concerns with the child or young person’s school/education setting -staff in education can discuss with you and support with this as well as discuss with other colleagues i.e. SEND and colleagues within health such as primary mental health workers and health-led drop In sessions.  A referral can then be completed where needed.

In addition, and particularly where the child or young person is electively home-educated, please access one of our drop in session to which you will be signposted too.

For all other concerns, complete the self-referral form below. All information submitted on this form will be treated with strict confidentiality.

If you have a parent or other adult who can support you to complete the form, they can help you to fill it in or fill it in for you.

Please phone free on 0800 121 7762  and choose option 0 (that is, Options4CYP Single Point of Access  if you have any queries).

We are available between 9am and 5pm, Monday to Friday, excluding bank holidays.

SECTION 1

Are you referring yourself? (If not, complete the form for the person you're referring and add your details in Section 4).
Have you accessed help from other mental health support services in the past e.g. counselling or school-based mental health support team? Required
If yes, was it related to your currently difficulty?
Do you have a physical condition you think we should know about? Required
Have you been diagnosed with or are under investigation for any other condition e.g. ADHD, ASD? Required
Required
Required
Required
Required
What is your preferred pronoun? Required
Date of birth Required
Your home address Required
Required
Required
Can we write to you at home? Required
Best time of day to contact you (you may choose both) Required
Can we leave you a message? Required
If yes, which of these options is ok (you may choose more than one)
If someone else answer, can we leave a message with them? Required
What is the best way to contact you? Required
If you are a young person referring yourself, are you happy for us to contact your parents if we cannot get hold of you directly? Required
Are you in foster care or other arrangements? Required
Do you have, or have you requested, an assessment for an EHCP? Required
Required

SECTION 2

Have you attended a Primary Mental Health Worker (PMHW) drop-in and been advised to complete a self-referral?
If so, which drop-in did you attend?
Which date did you attend the drop in?

SECTION 3

Which of the following have you experienced? Required
Thinking about the issues you ticked in the question above, when did the difficulties start (onset)? Required
Thinking about the issues you ticked in the question above, how often does this happen (frequency)? Required

How is this impacting your daily life?

Thinking about the following may help you to complete this section:

What impact is this having on your mood and your thoughts?  Are you thinking about harming yourself (if yes, please describe how often this happens? Can you share how you are thinking about harming yourself?)

Are you using alcohol or other substances to help you cope? If yes, can you tell us which substances and describe how often this happens?

Can you share anything that may have a happened in your life that maybe impacting on how you are feeling?  This could be about home/school/work/friendships/relationships or past/current experiences/stress.

If you were to receive support from one of our services, how would you know when things feel better for you? What change would you see or feel?

Required

What action has been taken to address your concerns? What has happened so far?

Thinking about the following may help you to complete this section:

Can you describe any support are you already receiving?  This might be support from school, your school nurse or GP or from a voluntary organisation.  Can you describe how often you receive this support and how it helps you?

Required

Do you feel that you are at risk? If yes, please give details

If you answer Yes to this question, we need you to give us more information please. Thinking about the following may help you:

How do you feel at risk?  How often do you feel like this? Have you told anyone about this already (if yes, who?)

Required
Are you caring for anyone?

SECTION 4

If you are referring someone else, please answer the next questions about yourself otherwise go to Section 5.

Your address
Is the young person aware this referral is being made on their behalf?

SECTION 5

Required