Referral or multi-agency meetings for assessment and advice to identify persistent and complex needs such as:

• Child and Adolescent Mental Health Service;

• Adult Mental Health Services.

• Bury Healthy Minds

• Early Intervention Team;

• 42nd Street;

• Educational Psychology Service;

• Occupational Therapy;

• Physiotherapy Service.

Increasingly individualised/adapted personalised programme of support.

Use of the Moving on Well resource pack. A resource aimed at improving transition practice for young people with complex health needs and disabilities.

Assist the young person to make themselves known to their GP before the transition to adult services.

Enable young people to start taking responsibility for managing their own health as appropriate (Mental Capacity Act).

Use of resources such as Transition Help for Communities.