Lamplight API response

Email address

Mobile phone

Phone number

By post

By email

By mobile

By text message

Child's information

Date of birth

Age of child at start of intervention

Academic Year Group

Gender

Ethnic origin

Preferred language

School information

School name

Date of referral

Referrer Name

Referrer Job Title

Referrer email address

Referrer contact number

Class teacher's name

Class teacher's email

Other relevant staff members

Family information

Family status

Parent/Carer Details: reminder - when parents are separated but both hold parental responsibility, we require contact and consent from both parents before proceeding with the Play & Creative Arts Therapy intervention.

Parent / carer 1 contact details

Parent/carer 1 name

Parent/carer 1 contact number

Parent/carer 1 email

Parent/carer 1 relationship to child

Parent / carer 2 contact details

Parent/carer 2 name

Parent/carer 2 contact number

Parent/carer 2 email

Parent/carer 2 relationship to child

Please give relevant information of current or previous input from services

Ed Psych

Yes

Ed Psych - phone number

Ed Psych - contact name

Ed Psych - email

CAMHS

Yes

CAMHS - phone number

CAMHS - contact name

CAMHS - email

Social Services

Yes

Social Services - phone number

Social Services - contact name

Social Services - email

HSLW

Yes

HSLW - phone number

HSLW - contact name

HSLW - email

Other relevant professionals

Yes

Other relevant professionals - contact details

Pupil premium

Medical Information

Any medical conditions

Medical condition details

Allergies

Allergies details

Any developmental conditions/ learning difficulties diagnosed or pending diagnosis

None

ADD

Autism

CAMHS referral

Dyslexia

Other

Any further additional needs details

Parts of this referral form may be quoted directly in the young person's end of therapy report, which may be passed onto the child’s parent/carer. The report may also be read by the young person themselves or other professionals.

Please consider using sensitive language when describing concerns and experiences.

Reasons for referral

(child's presenting needs)

Environmental issues summary

i.e. Any obvious difficulties thought to be impacting the wellbeing of the child

Other relevant information

Any other relevant information that will help the therapist to best support this child e.g. risk of absconding, risk of self-harm, risk of harm to others etc. Please note here or discuss with your therapist.

What differences would you like to see as a result of the child attending Play & Creative Arts Therapy?

Difference 1

Difference 2

Difference 3

Difference 4

School Consent and Data Protection (GDPR)

I confirm that I have permission from the child's parent / carer to give the information on this form to Clear Sky Children's Charity.

Yes

I understand that personal information will not be shared with any third-party organisations or agency except where there is a risk of harm to self or others, if required by law or if required under terms of the appropriate (GDPR compliant) regulatory or legal bodies.

Yes

I understand that anonymised data will only be shared as is required by appropriate authorities and governing bodies.

Yes

I understand that all data relating to this child, through work undertaken by Clear Sky Children's Charity:

Will be securely stored and processed in accordance with Clear Sky's GDPR policy and processes.

Will be made available or deleted if the parent /carer requests.

Play & Creative Arts Therapy Referral Form - CONFIDENTIAL - For Clear Sky Office use only

Other information