N.O.W.S

Self referral registration

Please use this form if you are an individual / family self-referral, looking to use our services.

Important

This form is only for self referrers who have received a letter from CAMHS Single Point of Access. Please continue to complete this self referral form and upload your letter at the bottom.

If you are wanting to make a new referral into NOWs please contact CAMHS Single Point of Access on 0800 9530222. If you are an organisation or GP please contact us for more information.

Parent / guardian First Name(s)

Parent / guardian Surname

Best contact telephone number

Parent / Carers contact number

Home address line 1

Main address for referral

Home address line 2

Home address - town

Home address - county

Home address - postcode

Email address

of Parent / Carer

Date of birth of child / young person

Please confirm DOB of the CYP being referred

First name(s) of child / young person for referral

Surname of child / young person for referral

If different to parent / guardian

NHS Number of everyone being referred in

Gender of referral

Female

Male

Other

Prefer not to say

Will the parent / carer being taking this programme also

yes

no

maybe

Programme Selection

Clinical Aromatherapy Consultation & Tailored Blend

6-8 weeks to Emotional Resilience And Wellbeing Kids (aged 4-7)

6-8 weeks to Emotional Resilience And Wellbeing Young People (aged 8-17)

6-8 weeks to Emotional Resilience And Wellbeing Adults

Test Test option

Please tick to agree to the following terms

I agree to be accountable for each session, to be educated on the wellbeing techniques that will be coached / mentored via N.O.W's Team.

I understand that I will be responsible for making the sessions (or for ensuring a minor taking the child course) on time and if for any circumstances the session cannot be adhered to the time / date booked, I have 48hrs before the date to notify N.O.W's head office by email or phone in order to reschedule the session.

If any session is missed and N.O.W's is NOT notified, the week will be deducted from the overall 6/12 week programme.

School Name

Name of the School for Referral

School Contacts Number

School SENCO/ Pastoral / Mental Health lead Email AddressEmail Address

GP Details

Please include GP Name, Surgery Address And Phone Number

Are you or the family member for referral(s) on any medication? If so please list

Have you got a neurological diagnosis?

Yes

No

Awaiting diagnosis

Self diagnosed

Includes all neurotypes under the neurodiversity paradigm (i.e Autism, ADHD)

Date of Diagnoses (only complete if you got a neurological diagnosis)

Approximated date of diagnoses

Accessibility needs

Yes

No

Not Sure

Please provide additional information to your accessibility needs in the additional notes question

Additional referral / notes

please include any other reasons, additional needs or disabilities

Please include details if the family is being supported by any other organisations

Have you tried any holistic therapies before? If so please list

Referral letter attachment

Please upload a copy of your referral letter.

Permissions

By submitting this form you are agreeing that N.O.W.S can contact you to discuss your referral on the contact details provided

New user registration

Self referral registration

Important