Professional’s Referral Form 18+(V2)
Checklist for referrers
(referrals must meet ALL of the following)
•	The client meets the service acceptance criteria (included 
•	The client has an Islington postcode or an Islington GP or attends education in Islington	

	

Data protection and confidentiality
In order to receive a service, some of the information you submit on this form will be shared with the child/young person’s GP and may also be shared with other relevant NHS services. The data provided will be stored on Barnardo’s computer file system.
This will be explained further at the initial assessment.

All sections marked with * are mandatory	

Details of the young person being referred	

*Surname 		*Date of birth		

*First name		*Gender 		
*Address		NHS Number		

*Postcode		Young Person Mobile 		

*Tel. No. (home)		*Email 		

*Ethnicity		Religion 		
Main language of young person		Interpreter required?	

 Yes   No 	

*Disability	
 Yes   No	Disability details		
Are you currently in education, employment or training?	
 Yes   No	
If yes, where?
		
Have you previously received any mental health support?	 Yes   No	If yes, what kind?		
Have you or your family ever been involved with social services? 	 Yes   No	If yes, please give details.		
*GP/Doctor details	
GP name: 	
Address: 	
Tel. No.: 	
E-mail: 	
Is anyone else helping you? If so, what service are they from?	

*Is the child/young person currently receiving any other    therapeutic intervention?
	 Yes   No   Don’t know 	
Details of other agencies / professionals involved (please add if required)	

Name		Name		

Role		Role		
Address		Address		

Contact No.		Contact No.		
E-mail		E-mail		

*What is causing concern? E.g. mental health difficulties, behaviours, emotional wellbeing and self-esteem issues?	

	
*What is you/child/young person/family hoping to gain from the referral?	
	
Another other relevant information	

*Referrer’s details 	
Date of referral		Consent obtained from young person to refer?	
 Yes    No  	
Name		
Agency		
Address	
	
Email		Tel. No.		
Print name		
Signature		
To be returned via your secure service communication method: 
-By hand or recorded delivery to 
 Harrow Horizons, Building 21, 21 Pinner Road, Harrow, HA1 4ES (020 8427 1322)
-Via encrypted email to harrowhorizons@barnardos.org.uk
-Via password protected document to harrowhorizons@barnardos.org.uk 
-NHS only – return to harrow.horizons@nhs.net

Islington Social Emotional Mental Health Service (SEMHS) 
Supporting children and young people’s emotional health and well-being in Islington

Referral Acceptance Criteria

Who we can see: 
Young People who are registered with an Islington GP, or who live within the borough of Islington, or attend school in Islington. From the age of 18 up to 25 and are presenting with one or more of the following:

•	Family issues – where this is having an adverse effect and the CYP is showing signs of developing a mental health problem/disorder
•	Mild to moderate emotional and behavioural disorders
•	Problems relating to behaviour (sleep, feeding, tantrums) once physical causes have been considered and the behaviour falls outside the range of  ‘normal’ behaviour
•	Conduct disorders
•	Low levels of anxiety, depression, stress and or other mood disorders,  or low self-esteem
•	Simple phobias 
•	Self-harm – where this is mild to moderate
•	Bullying
•	Anger management issues
•	Poor/distorted body image
•	Issues regarding: identity/gender/sexuality/race/culture/acculturation
•	Compulsive or obsessional behavioural patterns
•	Bereavement and/or loss (including anticipatory)
•	Mild Eating issues (not Eating Disorder where eligible for the Eating Disorders Service)
•	Relationship problems/Family relationship difficulties 
•	Experience of abuse (physical, emotional and sexual) and/or neglect
This also includes: Young people with Attention Deficit Hyperactivity Disorder, Autism Spectrum Disorders, Special Education Needs and Disabilities and Learning Disabilities. 

Exclusion criteria
•	Children and young people without an identified, sustained Emotional Health and Wellbeing need requiring targeted intervention (or ‘Tier 1’)
•	Children and young people requiring long term therapy
•	Children and young people requiring drug-based therapy
•	Children and young people in crisis, or requiring emergency or ‘Out Of Hours’ support
•	Children and young people with severe eating disorders 
•	Concerns/issues about attachment
•	Children and young people with psychosis or personality disorders
•	Young adults aged 25 or over.
•	Children and Young people currently receiving another therapeutic intervention

In cases where referrals are found to be inappropriate, we will refer or signpost the child/young person and their family/carers to other services (with prior consent)