Music Minds

Youth Support/Social Services/Agency Referral Form

For one-to-one music and mental health support sessions

CONFIDENTIAL

The purpose of these sessions are to support and empower young people with mental health problems – particularly those at risk of self-harming – to improve their mental health through singing, songwriting, music technology, and other forms of music making as appropriate to the young person.Where possible, we will also aim to link with other professionals (eg in APS and mainstream schools) through our existing work in other settings, as well as identifying and signposting sources of support for the young person’s continued involvement in music. Each young person may be eligible for between 2-10 sessions. Please read the referral criteria and process outlined on page two.

This programme is part of a pilot involving two secondary schools as well as the hospital education service and other statutory services and agencies working with young people, which has been funded by Youth Music, Gloucestershire NHS Clinical Commissioning Group, and Make Music Gloucestershire.

Referral criteria:

The young person will have at least two of the following criteria. S/he:

  • is judged by the referrer to have a mental health problem such as stress, anxiety, depression
  • is believed to be at risk of self-harm, or other negative coping strategy;
  • is not undergoing any other intervention;
  • may or may not have an expressed interest in music (not necessarily any experience in music);

Understanding and evaluating the impact of the programme is an important part of this project, and we will expect both professionals and young people to provide feedback and information to support this.

Referral process:

  1. Professionals working in Youth Support, Social Services, Hospital Education, CAMHS or other agency to contact Project Manager Anita Holford, or if more appropriate, The Music Works music leaders, Malaki Patterson or Misha Law to ask to refer a young person OR the music leader approaches a professional from either team to advise that the young person would be suitable.
  2. Music leader/Project Manager and professional speak to agree if this is an appropriate referral – both professionals must be in agreement.
  3. Professional liaises with young person/family as appropriate and if they are in agreement, completes this referral form.
  4. Sessions are arranged either at one of our studios, or in a suitable location local to the young person – depending on the criteria and the needs.

Specific outcomes and targets (in addition to overall project outcomes):

  1. Increased musical confidence and ability, increased musical engagement and confidence
  2. Increased in-depth knowledge of songwriting, music technology and music development
  3. Improved mental health including significant decrease in self-harming
  4. Improved understanding and expertise across the music sector of how to use music to improve health
  5. Improved understanding among health commissioners of the use of music in improving mental health and reducing self-harm
  1. Name of participant: …………………………………………………………………………………………….
  2. Are they: male [ ] female [ ] Date of birth: ……… Age: ………
  1. Contact name and tel no for parents: ………………………………………………………………….
  1. Please confirm that the young person has a mental health Yes [ ]No [ ]

Please tell us what it is, and any triggers we should be aware of:

  1. Please tell us if they have any special needs, disabilities, or illnesses we should be aware of:
  1. Schooling:

Please tell us any information about their schooling, including any mainstream school/APS attended currently/in past/in future:

  1. Referral terms:

Please state any particular terms or stipulations for the referral, be it staff (ie female/male preferred), location (ie home, studio, hospital, hospital classroom, mainstream school for continuation/transition sessions), timings etc...

  1. Needs:

Please state needs of the young person you have referred, any prior relevant history, relationship to music.

  1. Potential Outcomes:

Please state potential outcomes for the young person. The Music Works will be working with the young person to develop their own personal outcomes which will be circulated to you.

  1. Additional input:

If there are any other issues that we need to be aware of, or resources needed, please share this with us.

Please return this form to: OR OR