EBSA Support Referral Form
Please complete the referral form below if you would like support for a family and child affected by  EBSA (Emotionally Based School Avoidance).
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Your Name *
Relationship to the Child: *
Parent/Carer name (if not self-referral)
Professional Role (if not self-referral)
Child's Name *
Child's DOB *
MM
/
DD
/
YYYY
Name of School, or Educational Establishment. 
(Please name the school that the child is currently registered to, attended last, or was last registered to, if de-registered.)
*
Local Authority the School or Educational Establishment is under *
Family Home Address *
Your Email Address *
Parent Email Address (if not self-referral)
You Phone Number (optional)
Parent Phone Number (optional if not self-referral)
What is going well for the child? (e.g. Academic, social, emotional, goals and ambitions etc.) *
What are you concerns about the child? *
At this moment in time the child is... *
Required
How long has the child been impacted by their difficulties? *
Additional Comments
How would you describe the child? *
Required
What support is in place, or has been in place in the past? *
Do you have any additional information to add, if not already mentioned?
Would you be willing for your information to be used for research purposes, with specific details changed to keep anonymity (name, age, schools, location etc.). You can change your mind at a later date if necessary. You can speak to DASH Mental Health, Wellbeing & Behaviour about this if you are unsure.  *
Would you be happy for any information collected through assessments and questionnaires to be used as research. Specific details will be changed to keep anonymity (name, age, schools, location etc.). You can change your mind at a later date if necessary. You can speak to DASH Mental Health, Wellbeing & Behaviour about this if you are unsure.  *
If you are responded yes to the above, please create your own unique identifier using the following format: Last two letters of your surname and the day and month of your date of birth in a 4 digit format. eg. Jones October 5th would be ES0510
Survey Information
The following section is just for survey purpose. It is looking at specific factors around you and your child. 

Adverse Childhood Experiences (ACEs) are:
  • Physical abuse.
  • Sexual Abuse.
  • Emotional Abuse.
  • Physical Neglect.
  • Emotional Neglect.
  • Living with someone who abused drugs/alcohol.
  • Exposure to domestic violence.
  • Living with someone who has gone to prison.
  • Living with someone with serious mental illness.
  • Parental Divorce/Separation.
Please select the following that are relevant for the child
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This form was created inside of Dash Mental Health, Wellbeing & Behaviour. Report Abuse