Support request form improvements

Please note: this is not an emergency service.

Do you need support with the health and wellbeing, physical or emotional health, of a child or young person aged 0-19 residing within Kirklees?

The form below is for young people, parents/carers and professionals to access Thriving Kirklees services. That includes:
- 0-19 Team (Health Visitors and School Nurses)
- Breastfeeding support
- Support for children and young people’s emotional and mental health (ChEWS and CAMHS)
Criteria:
- 0-19 Team – must live and/or attend a school in Kirklees
- CAMHS – must have a Kirklees GP and service is for age group 0-18 only
Please note: to access Home-Start Kirklees services ONLY, please ring 01484 421925.

To access Safety in the Home or Safety Rangers please call Yorkshire Children's Centre on 01484 415465.

For referrals to Neuro development assessment (Autistic Spectrum Conditions ADHD) please phone 01484 343184

For all other services please fill in the form below.

All fields marked with an asterisk are mandatory.
Please tell us who you are*
- A young person (aged 0-19 or up to 25 years for those with additional needs) wanting help
- A parent/family member/carer requesting help for a child or young person
- A parent/family member/carer requiring support or advice for themselves
- A professional involved in a child, young person or family’s care
- Alternative Provision Setting (PRU) only
- Commissioned School only
A young person
The information you provide is confidential, however we need to let you know that the information you give us on this form will be shared with the provider(s) in Thriving Kirklees we think can best help you. This includes Locala Community Partnerships, South West Yorkshire Partnership Foundation Trust, Northorpe Hall Child and Family Trust, Home-Start Kirklees and Yorkshire Children’s Centre. If any of the information you have given us suggests that you or someone else is at risk we may need to share this with other organisations outside of Thriving Kirklees.
Please check the box to confirm you are happy for your information to be shared in this way and for us to contact you on the number you give us:*
- I confirm
Your GP may also be able to see that you have asked us for help, your GP is a health professional who also must keep information confidential. Please tick below to say that you are ok with this.*
- I confirm
If you are unable to submit this form for any reason please ring us instead on 0300 304 5555.
Young person's name*
First Last
Young person's date of birth*

Day
Month
Year
Young person's phone number*
Young person's email address

If email address is blank we will not be able to tell you that we have received your support request
Young person's address*
Address Line 1 Address Line 2 Town/City Postcode
School name*
Name of General Practitioner *
Name of General Practicitioner*
General Pracitioner
- I don't know
Please tell us more about how we can help you*
What are you worried about? How long has this been going on for? What do you think caused it to start? When did it start? How does it effect you day to day? Who else knows about this? Are you worried about hurting yourself and/or others? (i.e. self harm, aggression & suicidal thoughts) Do you hurt yourself or others? (i.e. self harm, aggression & suicidal thoughts)
What is your religion?*
What is your main spoken language?*
Is an interpreter needed?*
- Yes
- No
Are there any communication needs for you or your parent/carer?*
- Yes
- No
For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s.
What might be helpful when communicating with you or your parent/carer?
Name of parent/carer
Phone number for parents
What is the best time to contact you?*
Please note every effort will be made to take into account this preference however we cannot guarantee your call back will be within these times
Thank you – once you submit you will get an email to let you know we have got your form as long as you have filled in your email address above.

Please note you may need to check your junk or spam folder for the confirmation email which will come from noreply@locala.org.uk.
Parent/Family member/Carer requesting help for a child/young person
The information you supply on this form will be shared on a need to know basis with the provider(s) within Thriving Kirklees that we think can best help you. This includes:
- Locala Community Partnerships
- South West Yorkshire Partnership Foundation Trust
- Northorpe Hall Child and Family Trust
- Home-Start Kirklees
- Yorkshire Children’s Centre
The partnership also works closely with GPs and they may be able to see the information you supply. If any of the information you have given us suggests that you or someone else is at risk we may need to share this with other organisations outside of Thriving Kirklees.
Please check the box to confirm you are happy for your information to be shared in this way and for us to contact you on the number you give us:*
- I confirm
If you are unable to complete this form or you do not wish to check the box above please ring us instead on 0300 304 5555.
Please tell us your relationship to the child/young person*
- Relative
- Carer
- Other
Please tell us how you are related e.g. Mother, Father, Aunt, Uncle, Grandparent etc.*
Please tell us what kind of care you provide e.g. foster care, homecare etc.*
Please tell us your relationship to the child/young person*
Details about the child/young person
Child/young person's name*
First Last
Child/young person's date of birth*

Day
Month
Year
Child/young person's address*
Address Line 1 Address Line 2 Town/City Postcode
School name*
Name of General Practitioner *
Name of General Practicitioner*
General Practitioner
- I don't know
What is the child/young person's main spoken language?*
What is the child/young person's religion?*
Does the child/young person have a disability?*
- Yes
- No
Is the child/young person LAC?*
- Yes
- No
Other services supporting you or the family
i.e Social Worker
Details about parent/family member/carer 1
Parent/family member/carer name*
First Last
Parent/family/member/carer address
- New address
- Same as young person's address
Parent/family member/carer address
Address Line 1 Address Line 2 Town/City Postcode
Parent/family member/carer phone number*
Parent/family member/carer email address

Needed to send you confirmation your form has been submitted
Details about parent/family member/carer 3
Parent/family member/carer name*
First Last
Parent/family/member/carer address
- New address
- Same as young person's address
Additional parent/family member/carer address
Address Line 1 Address Line 2 Town/City Postcode
Parent/family member/carer phone number*
Parent/family member/carer email address

Needed to send you confirmation your form has been submitted
Do you know which area of Thriving Kirklees you want to connect with?*
- Emotional Wellbeing and Mental Health Concerns (ChEWS and SWYFT CAMHS)
- CAMHS LD
- 0-19 (Locala Health Visiting and School Nursing)
Please tell us more about why you are contacting us*
Who are you worried about? What are worried about? How does this impact on the child or young person? How do they appear day to day? How long have you been worried for? When did it start? Do you have any concerns around risk to self (i.e. self harm, aggression or suicidal thought) What have you tried to help the current concern?
Is an interpreter needed?*
- Yes
- No
Are there any communication needs for this child/young person or yourself?*
- Yes
- No
For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s.
What might be helpful when communicating with this child/young person or yourself?
Is the child/young person aware of this support request?*
- Yes
- No
- Unknown
Where appropriate can we contact the child/young person directly?*
- Yes
- No
Child/young person’s contact number
What is the best time to contact you?*
Please note every effort will be made to take into account this preference however we cannot guarantee your call back will be within these times
Thank you – once you submit you will receive an acknowledgement via email that your support request had been received as long as you have supplied your email address.
A parent/family member/carer requiring support or advice for themselves
The information you supply on this form will be shared on a need to know basis with the provider(s) within Thriving Kirklees that we think can best help you. This includes:
- Locala Community Partnerships
- South West Yorkshire Partnership Foundation Trust
- Northorpe Hall Child and Family Trust
- Home-Start Kirklees
- Yorkshire Children’s Centre
The partnership also works closely with GPs and they may be able to see the information you supply. If any of the information you have given us suggests that you or someone else is at risk we may need to share this with other organisations outside of Thriving Kirklees.
Please check the box to confirm you are happy for your information to be shared used in the way described above and for us to contact you on the number you have given:*
- I confirm
If you are unable to complete this form or you do not wish to check the box above please ring us instead on 0300 304 5555.
Parent/family member/carer name*
First Last
Parent/family member/carer date of birth*

Day
Month
Year
Parent/family member/carer phone number*
Parent/family member/carer email address

If this is blank we will not be able to tell you that we have received your support request
Parent/family member/carer address*
Address Line 1 Address Line 2 Town/City Postcode
Please tell us more about why you are contacting us*
What are you worried about? What support are you are looking for? What have you tried to help the current concern?
Is an interpreter needed?*
- Yes
- No
Are there any communication needs for you?*
- Yes
- No
For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s.
What might be helpful when communicating with you?
What is the best time to contact you?*
Please note every effort will be made to take into account this preference however we cannot guarantee your call back will be within these times
Thank you – once you submit you will get an email to let you know we have got your form as long as you have filled in your email address above.
Professional involved in the child/young person’s care
Information disclosed on this form will remain confidential and shared on a need to know basis between the providers in the Thriving Kirklees partnership. This includes Locala Community Partnerships, South West Yorkshire Partnership Foundation Trust, Northorpe Hall Child and Family Trust, Home-Start Kirklees and Yorkshire Children’s Centre. If there is a risk to the safety of the child, young person or others, the information may be shared with relevant authorities outside of the partnership.
Please check the box to confirm you are happy for your information to be shared in this way and for us to contact you on the number you give us:*
- I confirm
Are parents aware of this support request and consent?*
- Yes
- No
Is the child deemed Gillick competent and has consent to this referral?*
- Yes
- No
This referral will be declined as consent must be gained. Please gain consent and then return here to make the referral.

Safeguarding issues should be referred to social care via 01484 414960
Details about you, the person requesting the support on behalf of the family/child/young person:
Professional's name*
First Last
Professional's address*
Address Line 1 Address Line 2 Town/City Postcode
Professional's role/Job Title*
Professional's organisation name*
Professional's email address
Professional's phone number*
Do you know which area of Thriving Kirklees you want to connect with?*
- Emotional Wellbeing and Mental Health Concerns (ChEWS and SWYFT CAMHS)
- CAMHS LD
- 0-19 (Locala Health Visiting and School Nursing)
Details about the child/young person
Child/young person's name*
First Last
Child/young person's date of birth*

Day
Month
Year
Child/young person's NHS Number (if known)
Child/young person's GP
Child/young person's address*
Address Line 1 Address Line 2 Town/City Postcode
What is the child/young person's religion?*
What is the child/young person's main spoken language?*
Is an interpreter needed?*
- Yes
- No
Are there any communication needs for this child/young person or their parent/carer?*
- Yes
- No
For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s.
What might be helpful when communicating with this child/young person their parent/carer?
Does the child/young person have a disability?*
- Yes
- No
Who is the child/young person living with?
Is the child/young person LAC?
- Yes
- No
Please tick if any of the following apply*
- Adopted
- Care Order
- EHC Plan
- Interim Care Order
- Special Guardianship
- Placement Order
- Subject to Early Help Assessment (EHA), Single Assessment/CAF
- Section 17 Child in Need
- Section 20 Voluntary Care
- Section 47 Child Protection
- None of the above
- Unknown
Are you aware of any Safeguarding concerns?*
What are the possible risks to self (self harm, aggression, suicidal thinking)
Is the child/young person aware of this support request?*
- Yes
- No
- Unknown
Reason for support request?*
Where appropriate can we contact the child/young person directly?*
- Yes
- No
Child/young person’s contact number
Details of parent/carer 1
Parent/carer name
First Last
Parent/carer contact number
Parent/carer address
- New address
- Same as young person's address
Parent/carer address
Address Line 1 Address Line 2 Town/City Postcode
Details about the parent/carer 2
Parent/carer's name*
First Last
Parent/carer's contact number*
Parent/carer's relationship to child/young person*
Parent/carer address
- New address
- Same as young person's address
Parent/carer's address (if different to child/young person)
Address Line 1 Address Line 2 Town/City Postcode
Can we contact the parent/carer(s) directly?
- Yes
- No
Can we contact the school/college directly?*
- Yes
- No
Are you aware of any other professionals involved in their care? Please provide details.*
Thank you – once you submit you will get an email to let you know we have got your form as long as you have filled in your email address above.
Alternative Provisional Setting (PRU)
The information you provide is confidential, however we need to let you know that the information you give us on this form will be shared with the provider(s) in Thriving Kirklees we think can best help you. This includes Locala Community Partnerships, South West Yorkshire Partnership Foundation Trust, Northorpe Hall Child and Family Trust, Home-Start Kirklees and Yorkshire Children’s Centre. If any of the information you have given us suggests that you or someone else is at risk we may need to share this with other organisations outside of Thriving Kirklees.
Young person's name*
First Last
Young person's date of birth*

Day
Month
Year
Young person's address*
Address Line 1 Address Line 2 Town/City Postcode
What is your religion?*
What is your main spoken language?*
Is an interpreter needed?*
- Yes
- No
Are there any communication needs for you or your parent/carer?*
- Yes
- No
For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s.
What might be helpful when communicating with you or your parent/carer?
Parent/family member/carer name*
First Last
Young person's phone number*
Young person's email address

If email address is blank we will not be able to tell you that we have received your support request
Please check the box to confirm you are happy for your information to be shared in this way and for us to contact you on the number you give us:*
- I confirm
Setting or school name*
Please tell us more about how we can help you*
Commissioned School
The information you provide is confidential, however we need to let you know that the information you give us on this form will be shared with the provider(s) in Thriving Kirklees we think can best help you. This includes Locala Community Partnerships, South West Yorkshire Partnership Foundation Trust, Northorpe Hall Child and Family Trust, Home-Start Kirklees and Yorkshire Children’s Centre. If any of the information you have given us suggests that you or someone else is at risk we may need to share this with other organisations outside of Thriving Kirklees.
Young person's name*
First Last
Young person's date of birth*

Day
Month
Year
Young person's address*
Address Line 1 Address Line 2 Town/City Postcode
What is your religion?*
What is your main spoken language?*
Is an interpreter needed?*
- Yes
- No
Are there any communication needs for you or your parent/carer?*
- Yes
- No
For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s.
What might be helpful when communicating with you or your parent/carer?
Parent/family member/carer name*
First Last
Young person's phone number*
Young person's email address

If email address is blank we will not be able to tell you that we have received your support request
Please check the box to confirm you are happy for your information to be shared in this way and for us to contact you on the number you give us:*
- I confirm
Setting or school name*
Please tell us more about how we can help you*

A young person

Parent/Family member/Carer requesting help for a child/young person

Details about the child/young person

Details about parent/family member/carer 1

Details about parent/family member/carer 3

A parent/family member/carer requiring support or advice for themselves

Professional involved in the child/young person’s care

Details about you, the person requesting the support on behalf of the family/child/young person:

Details about the child/young person

Details of parent/carer 1

Details about the parent/carer 2

Alternative Provisional Setting (PRU)

Commissioned School