Dramatherapy Referral Form

Name (required)

Phone number (required)

E-mail (required)

Contact address (required)

Postcode (required)

Date of birth (required)

Gender (required)

Pronouns (required)

Ethnicity (required)

Disclosed disability (required)

Name of school/college/employer/training provider if applicable (required)

What is the best way of making initial contact with the young person? (required)

Other details that might assist CYN with the appropriate allocation e.g. English as a second language, LDD, sensory impairment, known medical condition. (required)

Please enter details below if there are any other agencies working with the young person and/or the members of his/her family that we should know about. (required)

Reasons for referral (required)

Is the young person aware of the referral? (required)

YesNo

Is the young person willing to engage for 12 sessions? (required)

YesNo

Would this young person benefit from working with a wellbeing practitioner (Mild to moderate mental health needs):

Anxiety (general or social)Low mood/depressionObsessive Compulsive Disorder (OCD)Panic DisorderChallenging Behaviour

Other, please state:

Have they been referred to CAMHS?

YesNoUnsureIn the past

If yes, have they been accepted?

YesNo

Has the young person experienced any Adverse Childhood Experiences (ACEs)? Mark all that apply:

Physical abuseSexual abuseEmotional abuseLiving with someone who abused drugsLiving with someone who abused alcoholExposure to domestic violenceLiving with someone who was incarceratedLiving with someone with serious mental illnessParental loss through divorce, death or abandonment

Dramatherapy Referral Form

Referrer’s Details

Young Person’s Details