Parental Consultation Request Form

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The purpose of this service is to support parents in supporting the emotional wellbeing of their children during this time. Things you may wish to discuss about your child could include:

their general emotional wellbeing at this time
how they are coping with social distancing and lack of contact with family and friends
family concerns
concerns around school work/returning to school
feelings of anxiety

You will speak to a School Based Counsellor who will be able to guide you in supporting the emotional wellbeing of your child.

You will be offered an initial telephone consultation of 30 minutes, dependent upon you and your child’s needs, and a potential follow-up of another 30 minute telephone consultation at a later date.

These will be Monday to Friday within standard working hours. If you would like to access the service, please complete the following form:

1.1. Referral date Required

(dd/mm/yyyy)

2.2. Your name Required

a.2.a. Your email address Optional

b.2.b. Telephone number you would like to be contacted on Required

c.2.c. Times and dates you are NOT available for consultation

3.3. Your child/children's Full Name Required

a.3.a. Your relationship to child e.g. parent, legal guardian Required

4.4. Your child/children's Date of Birth

(dd/mm/yyyy)

5.5. Your child/children's Gender Required

Male

Female

6.6. Name of your child's school Required

7.7. Year group Required

8.8. Reason for wanting a consultation (tick up to 3 as appropriate) Required

9.9. Tell us a little about the concern you would like to discuss Required

10.10. Are there any current or pending police investigations or court proceedings that relate to the child? Required

Yes

No - go to Q13

a.10.a. If Yes, please provide further details: Optional

Police Investigation

b.10.b. Investigating Officer Name Optional

i.10.b.i. Contact Details Optional

Court proceedings

c.10.c. Name of ISVA and/or Social Worker Optional

i.10.c.i. Contact details Optional

11.11. Any other services/professionals involved in child’s welfare (select as appropriate)

EP Service

Behaviour Support Service

Education Support Worker

Child Protection Register

Education Welfare Service

Advisory Teacher

(LAC) Social Services

Health Professionals

12.12. Does the young person have special educational needs (SEN) or a disability?

Yes

Don't know

a.12.a. If yes, please select from drop down list Optional

b.12.b. If yes, please provide further details Optional

c.12.c. Date of Special Educational Needs Statement Optional

Dates need to be in the format 'DD/MM/YYYY', for example 27/03/1980.

(dd/mm/yyyy)

This part of the survey uses a table of questions,

13.13. Consider your observations of the child over the last two weeks and respond to the following statements below Required

	Strongly Agree [3]	Mostly Agree [2]	Mostly Disagree [1]	Strongly Disagree [0]	Don't know [0]
The child appears often unhappy or regularly cries
The child appears withdrawn
The child gets angry or lashes out at people
The child seems anxious or panicky
The child is often tired or struggles to sleep
The child displays dangerous behaviour putting themselves or others at risk of harm
The child has difficulty with friendships
The child talks negatively about themselves
Overall the child’s difficulties have an impact on their school life
Overall the child’s difficulties have a negative impact on their home life

14.14. I have read and understood the Parent Consent Information & Privacy Notice Required

Yes