Single Session Consultation – self referral form 2023/24

Referrals for this offer will be closing on Friday 21st June for the Academic year. If you would like to receive support this term, please make sure that your referral is submitted before the deadline.

The Schools & Colleges Early Support Service (SCESS) is a young people’s service provided by Anna Freud.

The Single Session Consultation is for young people who are 16-25 who are experiencing low to moderate difficulties such as anxiety and low mood. The consultation is a single video call session of support with a SCESS trained practitioner. It is based on solution focused brief therapy and focuses on finding solutions rather than identify what might be the underlying problem. The role of the practitioner is to empower the young person to take at least a small step towards their goal. The young person will agree an action plan with the practitioner.

We can only accept requests for support from young people who are a pupil at one of the partner schools or colleges of SCESS.

Whilst our service is confidential, we work with a key adult in your school or college. By completing this form you are agreeing to share your information with us and them.

This key adult who can support you in accessing the service remotely and will be our key contact for safeguarding purposes. For example, if you share you are at risk of harm when receiving support from us, or do not attend sessions without letting us know, we will share this with them. If you are aged 16 or 17, we also require your parent or carer details for safeguarding purposes.

The SCESS is not suitable for all young people. We cannot provide support to young people who are already accessing support for their mental health from another service, or who are on the waiting list for an appointment with NHS Children and Young People’s Mental Health Services.

If this offer is not currently suitable for you, other support near you can be explored using our Youth Wellbeing Directory: https://www.annafreud.org/on-my-mind/youth-wellbeing/

The following services are open to all young people, 24 hours:

SAMARITANS: 116 123 / www.samaritans.org
CHILDLINE: 0800 1111 / www.childline.org.uk
AFC and Shout Crisis Textline: TEXT: AFC to 85258

SCESS is not an urgent or emergency service. If you feel you are at risk of harming yourself, please contact your GP, attend the nearest A&E department or call 999 as a matter of urgency.

Call the NHS emergency number 111 if:

You need medical help fast but it's not a 999 emergency 
You think you need to go to A&E or need another NHS urgent care service 
You don't know who to call or you don't have a GP to call 
You need health information or reassurance about what to do next

We hold all information confidentially, including information relating to equity & diversity, such as ethnicity & gender. As part of our service evaluation, we may use some information to monitor and identify where we need to focus efforts to ensure we are reaching a representative audience. For information on how we will use your data please refer to our privacy notice: https://www.annafreud.org/your-privacy/

One of our team will contact you within 5 working days to discuss next steps.

Personal details

3. Your first name

4. Your last name

5. Your preferred name

Please complete even if it is the same as your first name.

6. Your home address

Please give full postal address of where you live now. Do not include postcode.

7. Your postcode

Please give the full postcode of where you live now.

8. What is your date of birth?

9. Your preferred pronouns

Other pronoun, please write here

10. Your mobile number

11. Your school/college email address

We are unable to consider your self referral if you do not give your school email ID.

12. Name of your school or college

Please give the full name of the school or college. Not giving the full name will slow down the processing of your referral.

13. What School or College year are you in?

14. What times are you available for an appointment? Please note, we can only call you between 09.00 and 18.00 Monday - Thursday, and 09.00 - 12.00 Friday

15. What times are you not available for an appointment? If we are able to proceed with supporting you we will need to contact you to discuss your needs in more detail. Please be as specific as possible about times you are not available over the next two weeks. We can only call you during our opening hours; 09.00 and 18.00 Monday - Thursday and Friday 09.00 - 12.00

Referral details

16. Reason for referral

17. The service we provide supports young people experiencing mild to moderate anxiety and / or low mood. This might look and feel like some of these things listed below. Are you experiencing any of the the following? You can select as many options that apply to you as you wish.

To select more than one option press 'ctrl' , hold down and click on options that apply.

18. How do the issues raised in the question above impact you at home and in school / college?

19. How long have you been experiencing difficulties with your mental health and wellbeing?

2-3 weeks4-6 weeks7-9 weeks10 weeks or more

20. Have you previously accessed support for your mental health and wellbeing?

YesNo

21. What support have you previously accessed to support your mental health and wellbeing?

22. Are you currently receiving any support or on the waiting list for another service for your mental health and wellbeing?

YesNo

23. What support are you currently accessing or on the waiting list for?

24. What are your expectations of the support from this referral to the Schools and Colleges Early Support Service?

For example, to be able to manage stressful situations more easily/to help with better sleep routines/ to help me with my low mood?