Are you looking for support for yourself or a child you care for? *
If you are answering on behalf of your child, what is their full name?
Your answer
What is your, or your child's date of birth? *
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What is your, or your child's gender? *
Your answer
What is your, or your child's ethnicity? *
Your answer
What is your home address? *
Your answer
What is the name and address of your child's GP? *
Your answer
Which hospital provides your child's physical health care? *
Please provide the Sheffield Children's Hospital Number (C number) or NHS number of either yourself or your child (if not known please put "unknown"). *
Your answer
What is the name of the medical consultant you receive care from at Hospital? *
Your answer
What medical speciality is this consultant from? *
Your answer
Please provide a brief description of the current difficulties and how this relates to physical health (and how long it has been happening for)
Your answer
What are the impacts on the current mental health difficulty on other areas of life (such as school, home, activity, friendships)?
Your answer
Safety: are there any known current or historical thoughts, plans or intent of suicide, self-harm or other risk factors? *
Your answer
Please provide an email or contact phone number so that we can get in contact with you. *
Your answer
If there is any other information that you would wish to share, please use this space below.
Your answer
The Lucy Project is a service supporting young people with mild to moderate difficulties around their mental health which are directly related to their physical health. By submitting this form you acknowledge that this particular service and model of video-based low-intensity input will not be suitable for all young people. The Lucy Project will offer an assessment call and therapeutic service for young people where their difficulties are related to their physical health. Where this isn't the case and physical health is not a primary aspect of their difficulties, we will offer a signposting service which we will communicate to you via letter. *
Required
Disclaimer - Information sharing: In order to provide best-practice health care we will share appropriate clinical information with your local health care team such as your Paediatrician or GP. This ensures collaborative health care, enhances safety and prevents duplicate referrals.
Disclaimer: The Lucy Project is not an emergency contact and submissions to this form are not monitored out of office hours. If you have any immediate questions then please contact your GP. If you are experiencing a mental health crisis or emergency please call 999 for emergency support.
Thank you for completing this form. Once you press submit then a copy of the form will be sent directly to our team who will be in contact as soon as possible. If you have any further queries please call: 0114 2717296