Thriving Minds Referral Form
Linking Routes
The Palace Hub
28-29 Esplanade
Redcar
TS10 3AE

Tel: 01642 989198
https://www.linkingroutes.org.uk/
email: info@linkingroutes.org.uk
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The Thriving Minds project offers low level support for young people aged 14 years plus, through 1:1 outreach support and groups either in school, college or the community.  Untitled Title
Support for 1:1 outreach can cover - building friendships; confidence and resilience; anxiety; stress and emotional wellbeing.  During outreach we work through strategies, tailoring programmes and resources to help with the young persons issues.
We offer outreach for young people on a 1:1 basis initially for 6 weeks with outcomes and goals assessed at regular intervals throughout.
During any of our contact, concerns may arise for the need of higher level of support, this is where we can help and support the family to refer the young person, to ‘getting help’ or ‘getting more help’.
Linking Routes offer low level support of 'thriving' and 'getting advice'. 


Professional Agency Information
The next 4 question are to be completed by a professional referrer -
If you are self referring jump to 'how did you hear about us'
Professional Agency Information 
Name of Referrer
Referring Agency
Referrers Telephone Number
Referrers Email Address
How did you hear about us
Clear selection
Personal Information
YP First Name *
YP Surname *
Postcode
 *
Address
 *
Contact Phone number *
Contact Email Address *
Parent/Guardian Name (if under 16) *
Parent /Guardian Phone Number *
Relationship to Young Person  *
Date of Birth
 *
MM
/
DD
/
YYYY
Gender
Ethnicity
Emergency Contact -  Name and contact number -
Relationship to young person
GP Name *
GP Address, Postcode and contact number
 *
Allergies and/or Dietary Conditions
Any Medical Conditions
Medication
Education setting if applicable
Is the Young Person on Free School meals
Does the Young Person have a Caring Role
Reason For Referral  (this section must be filled out in detail to accept the referral)
How can we help? - What do you hope to gain from us? (please give a as much information as possible) *
Are any other Agencies Involved: 
If you have or are having support from another service, please give further details such as diagnosis, and if secondary services are involved such as CAMHS.   *
Do you or the young person present any risk to self or others? (Mental Health, self-harm, behaviours, physical health) *
Please choose which provision you may be interested in *
Required
Please tell us if you are related to a staff member here at The Link Charitable Trust *
Consent and Signature
CONSENT

Any personal data provided by you to The Link Charitable Trust  through any means (verbal, written, in electronic form, or by your use of our website) will be held and processed in accordance with the data protection principles set out in the Data Protection Act 1998 and the General Data Protection Regulation for the purposes for which you have given consent, to provide the services you have requested from us, and to meet the legitimate interests of the charity.

We reserve the right to change our decision and will inform the referrer of this action immediately.

LCT GDPR Data Protection Policy

LCT GDPR Policy on your Rights in Relation to your Data

LCT Privacy Statement


(Parent/guardian to sign on behalf of any young person under the age of 12 years)

Please Print your Full Name:

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or verbal consent given to referrer:
Name of referrer gaining verbal consent:
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Date *
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