Lamplight API response

First name

Last name

Address 1

Address 2

Address 3

Postcode

Email address

Mobile phone

We would like to contact you to arrange appointments or to talk to you about our services. We would like to text you reminders of your sessions. Please include the mobile number and email of the person who should receive this information (this could be a parent / carer) You can opt out whenever you like, and we won't share your contact details with any other organisations. Are you happy for us to contact you:

By post

By email

By mobile

By text message

Other information

NHS No

Date of birth

Gender

Is your gender identity the same gender you were assigned at birth?

Sexual Orientation

Ethnicity

Are there any addional requirements you would need to access the services

Child status (Please tick any that apply)

Are there any other professionals involved? eg social worker, CAMHS

Name of Doctor's surgery

May we contact your GP surgery if we require additional infromation?

Do any of the following Health, SEND or disability categories apply to you?

Is there any further Health, SEND or Disability information you would like to share with us?

Are you currently attending school or college? If yes please add the name of the school or college below

Are you taking any medication?

If yes - details of medication

Emergency Contact name

Emergency Contact Telephone No

Relationship to Young Person

Outside of emergencies may we contact your emergency contact if we are unable to contact you?

Have you accessed counselling in the last 12 months?

Reasons for referral

Please give us some more details of the reason for your referral.

Referral Source

If Parent / Carer or Professional is the Young Person aware you are completing this referral?

If Proffessional please add your name and contact details below

Details of Young Person

Other information