Lancashire LINK - Self referral application - St Fillan's Medical Centre

Reason you would like a referral

Please use this section to include as much information as possible. Including any significant life events, and highlight the young persons strengths and any support already in place.

What's working well: *

What are you concerned about? *

What do you think could help? *

Is the child/young person aware this referral has been made on their behalf? *

Yes No

If you have answered No to the above please explain why.

Is a parent/carer or responsible adult aware that you have made this application for yourself? *

Yes No

If you have answered NO to the above please explain why.

Please note, consent for referral also includes consent for data storage and sharing between your registered GP practice and Lancashire LINK. Please state if you approve to the sharing of the data within this form between your GP practice and Lancashire LINK Service in order for your application to be processed. *

I CONSENT

Lancashire LINK may re direct this referral to another agency if they believe they can provide more appropriate support. Please tick yes that you understand and consent to this in order for us to proceed with your application further. *

Yes No

Your referral may take up to two weeks to be processed. If you have not heard back from Lancashire LINK within this time please contact the surgery. *

I understand that Lancashire LINK/St Fillans Medical Centre do not have any safeguarding responsibility until the referral has been accepted by the service. *

YES

Should you feel you or the applicant needs more urgent support regarding their mental health or other medical concerns contact the GP surgery directly by phone or triage form. A GP will not see this application. *

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Lancashire LINK - Self referral application

Further Information