MindMate SPA

Who is filling out this form?*

A young person (for myself)
Adult on behalf of a child or young person
A health care professional on behalf of a child or young person

Young person details

First name(s)*

Last name*

Preferred name

Date of birth*

The young person is under 5 years old

Are they at primary school?

Yes
No

As you're under the age of 13, you'll need some help from an adult to complete this form. Please ask an adult to sit with you. They'll need to select "On behalf of a child or young person" at the start of this form.

Sorry, if the child is under 5 and not at primary school. You can’t refer them to MindMate SPA.

Please speak to your Health Visitor or GP in the first instance.

Sorry, MindMate SPA is for young people under 18 only.

View What's in Leeds for me 18-25 to find out about young adult services in Leeds.

As a health care professional, if you are working with children and young people and identify they have a need for support with their emotional wellbeing or mental health; you will need to fill in a different form.

Professional referrals

Parent/Carer details

Your first name(s)*

Your last name*

Relationship to child/young person

To process your referral we may need to contact you by telephone. If we can't reach you, we'll text you to let you know. We'll also let you know how long you have to reply to us.

Telephone number*

Verify telephone number*

Do you consent to receiving texts on the above number?

I consent to receiving texts on the above number

Email

Please complete your email address if you're happy to be contacted by email by MindMate SPA and the services we work with.

Enter Email Confirm Email

Are you the young person’s legal guardian?*

Yes

If you are not the legal guardian, then I'm afraid you can't proceed with this form.

Please send information about yourself and what problems you are having to the MindMate SPA team using this form. The form could take around 20-30 minutes to complete.

Once you press ‘submit’ the information will be sent securely to the team at MindMate SPA. SPA keeps your information private and confidential. We do share some details in order to:

make sure we have the right information to understand your needs
make sure you receive the correct support/service
to keep you or someone else safe
to help improve services

To process your referral we may need to contact you by telephone. If we can't reach you, we'll text you to let you know. We'll also let you know how long you have to reply to us.

Telephone

Verify telephone number

Do you consent to receiving texts on the above number?

I consent to receiving texts on the above number

Email

Please complete your email address if you're happy to be contacted by email by MindMate SPA and the services we work with.

Enter Email Confirm Email

What is your main spoken language?

What is your ethnicity?*

Gender

Please use this field to tell us your gender*

Address*

Address Line 1 Address Line 2 Town County Post Code

Your GP Surgery*

Please select your GP from the following list.

Name of your school or college

What are the things that you are currently struggling with?

Are you hurting yourself or thinking about self harm?*

Yes
No

MindMate SPA is not a crisis service. If you need urgent support around your mental health or feel you cannot keep yourself safe, please look at crisis information here for more immediate support Urgent help - MindMate & Urgent help - all services - MindMate

Do you have any thoughts or plans around self-harm at the moment? Has this been a concern before? When was the last time you self-harmed and what happened?

Have you ever tried to end your life, if so when?

MindMate SPA is not a crisis service. If you need urgent support around your mental health or feel you cannot keep yourself safe, please look at crisis information here for more immediate support Urgent help - MindMate & Urgent help - all services - MindMate

Have you been having thoughts about ending your life recently?*

Yes
No

MindMate SPA is not a crisis service. If you need urgent support around your mental health or feel you cannot keep yourself safe, please look at crisis information here for more immediate support Urgent help - MindMate & Urgent help - all services - MindMate

What kinds of thoughts are you having? Has anything happened recently to upset you?

Are you worried about your use of drugs or alcohol?*

Yes
No

When was the last time you had drugs or alcohol? What did you take and how much? Why does this worry you?

You may find this information useful Drugs and alcohol under 17 - MindMate.

Are you being hurt by someone?*

Yes
No

Has anyone hurt you in the past or recently? Have you told anyone about this, who?

If you have concerns that a child or young person is being harmed or is at risk of harm due to abuse and/or neglect, you must report this immediately. During office hours (Monday to Friday 9am-5pm, excluding Bank Holidays), you should contact Leeds Children’s Social Work Services on 0113 2224403. Outside office hours, report it to the police on 999. You may find this information useful Keeping safe - MindMate & Staying safe - MindMate.

Are you having thoughts about hurting others?*

Yes
No

What kinds of thoughts are you having? Who have you spoken to about this? How long has this worried you?

Do you have trouble sleeping?*

Yes
No

Do you find it easy to fall asleep or stay asleep? Are you always tired?

Do you have issues with eating or food?*

Yes
No

Have you lost weight very quickly, or do you spend a lot of time thinking about your weight, diet or your body? Include your height and weight if possible.

If you have concerns about an eating disorder presentation, please arrange an appointment with your GP/ Health Care Professional for up to date height and weight to be completed. You may find this information useful Worried about an eating disorder? - MindMate

Do you have any physical health issues?*

Yes
No

What are your health concerns?

Are you taking any medication?*

Yes
No

What medication are you taking? Why have you been given this medication?

If you are requesting a transfer of care or new referral for ADHD medication MindMate SPA require a copy of the full ADHD report to proceed with the referral. We recommend that you contact your GP to make this referral with the full report attached.

Is this relating to a neurodevelopmental concern such as Autism or ADHD?*

Yes
No

Is this an Autism/ ADHD concern or both – if so, have you already discussed this with school or a healthcare professional?

If you are requesting a transfer of care or new referral for ADHD medication MindMate SPA require a copy of the full ADHD report to proceed with the referral. We recommend that you contact your GP to make this referral with the full report attached.

Do you have problems concentrating?*

Yes
No

Have there been any recent changes? How long has this been an issue and what helps?

Do you have any issues with school/college/work?*

Yes
No

Please can you provide some details about these concerns e.g. attendance, schoolwork, friendships etc.

Do you have worries about life outside of lessons/work?*

Yes
No

E.g. your social life, interests, activities. Have there been changes to this recently?

Do you have concerns about your family?*

Yes
No

Are there problems with family relationships? Are there things that worry you about family members? Tell us if you are a young carer?

What issues would you like help with?

Please tell us a bit more about what is going on and why you are asking for support. You can give as much detail as you like (up to 1000 characters).

Please tell us which adults are supporting you or who knows about these issues e.g. a parent or family member, someone at school, someone who supports you like a counsellor or other worker.

Is there anything else you'd like us to know?

Yes
No

Please tell us:

Read our simple privacy guide

The information you provide here will be passed onto Leeds MindMate Single Point of Access which is part of Leeds Community Healthcare.

Confirm you understand who your message will be shared with?

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Mindmate

Contacting MindMate SPA

Who is this referral for?

Where does this information go?

Need an emergency service?

MindMate SPA referral form

Young person details

Parent/Carer details