Thrive Hubs Service Access Form

I'm a…*

Your Details: (Mandatory)

Your Child’s Details: (Mandatory)

Young Person’s Details: (Mandatory)

Age

Email Address*

Contact Number*

Gender*

Pronouns

Religion*

Ethnicity

First language

If "Other" selected please provide details

GP Name & address*

NHS Number

Your Family: (Mandatory)

Please tell us about family members

Family Information: (Mandatory)

Please tell us about family members

School / College Details: (Mandatory)

Name and Address:

Key Contact Name

Key Contact Role

Key Contact Email

Is there an Education, Health, and Care Plan (EHCP) in place?

Agencies/Professionals Involved: (Mandatory)

Are there any agencies currently supporting the you (such as TTT, 42nd Street, CAMHS, bereavement services, private counselling, etc)?

Agencies/Professionals Involved: (Mandatory)

Are there any agencies currently supporting the your Child (such as TTT, 42nd Street, CAMHS, bereavement services, private counselling, etc)?

Agencies/Professionals Involved: (Mandatory)

Are there any agencies currently supporting the young person (such as TTT, 42nd Street, CAMHS, bereavement services, private counselling, etc)?

Current Worries: (Mandatory)

What are your current worries?

Please provide as much relevant detail as possible:

What are the current worries for your Child?

Please provide as much relevant detail as possible:

What are the current worries for the young person?

Please provide as much relevant detail as possible:

What support is being provided now? What have school put in place? What support have you had in the past?

What support is being provided now? What have school put in place? What support has your child had in the past?

What support is being provided now? What have school put in place? What support has the young person had in the past?

Is there any historic or current self-harm / suicidal thoughts? If so, has a safety plan been completed? If not, why has no safety plan been completed?

Are there any additional needs/requirements to best support your Thrive Hub experience?

Are there any additional needs/requirements to best support your Child's Thrive Hub experience?

Are there any additional needs/requirements to best support the Young Person’s Thrive Hub experience?

Other Contextual Factors – Is there anything further you would like to share with Thrive Hubs?

Desired outcome of support from Thrive Hubs: (Mandatory)

Referrer Details: (Mandatory)

Submission Confirmation – Your Email Address

If you would like to receive an email notifying you that your email has been received please enter your email address.

Your Name*

Contact Number*

Email Address*

Your Name*

Your Organisation*

Contact Number*

Email Address*

*Thrive Hubs confirm that we will protect your privacy and will handle your data in accordance with GDPR 2018. Your data will only be accessed in relation to our hub procedures which includes sharing data within Thrive Hubs. This means your information will only be accessed by relevant hub staff as appropriate. Unless we have consent or the legal obligation to do so information will not be passed onto any other organisations. A full Data Protection Policy is available upon request from Thrive Hubs NHS.

Need Urgent Help?

Thrive Hubs Service Access Form

Service Access Form

Your Details: (Mandatory)

Your Child’s Details: (Mandatory)

Young Person’s Details: (Mandatory)

Your Family: (Mandatory)

Family Information: (Mandatory)

School / College Details: (Mandatory)

Agencies/Professionals Involved: (Mandatory)

Agencies/Professionals Involved: (Mandatory)

Agencies/Professionals Involved: (Mandatory)

Current Worries: (Mandatory)

Desired outcome of support from Thrive Hubs: (Mandatory)

Referrer Details: (Mandatory)

What do you need advice, help or support with?

What do you need help with?