Referral Form

This form must be completed to enable access to Wokingham Borough Council’s Emotional Wellbeing Hub or MHST teams.

If you are concerned that there is a risk to the life of a child or young person call 999. Otherwise, please visit the CAMHS website for contact information, including urgent or crisis support via https://cypf.berkshirehealthcare.nhs.uk/contact-us/

In order for the referral to be progressed, please indicate consent has been provided as below:

Parent/carer/young person 12+ have read and agree to the consent information provided on the website:*

Yes

Parent/carer/young person 12+ have read and understood the GDPR guidance on the website:*

Yes

Please Note: Young people aged 16 and above do not require parent/carer consent

How did you hear about our service?:

NHS Number (if known):

Title:

First Name:*

Preferred Name:

Surname:*

Address Line 1:*

Town/City:*

County:*

Postcode:*

Date of Birth:*

Gender:*

Male

Female

Non-binary

Other

If other, please provide details:

Is gender the same as assigned at birth?:*

Preferred Pronouns:*

Please select as applicable from the following:*

Ethnicity:*

Are they a young carer?:

Yes

No

Please select any that apply:

Please provide dates of diagnosis/referral, and other information:

Please indicate any accessibility requirements for child/young person/parent/carer? Type N/A if none are required:*

Please provide details of relevant professionals who have been involved with child/young person/family (name, contact details):

Where is education being provided?:*

Please provide the name of education setting:*

Please provide academic year:*

Please select if applicable:*

Education, Health and Care Plan

IEP

SEN Register

Pupil Premium

Please provide name, relationship to the young person, contact details and if they have legal responsibility below.

Person 1 Name:*

Is their address the same as the Child/Young person?:*

Yes

No

If no, please provide the address and postcode of Person 1.

Person 1 Address:

Person 1 Postcode:

Person 1 Relationship to the Child/Young Person:*

Person 1 Email:*

Person 1 Phone Number:*

Please confirm whether person 1 has:

Legal responsibility?:*

Yes

No

Consented to the referral?:*

Yes

No

Person 2 Name:

Is their address the same and the Child/Young person?:

Yes

No

If no, please provide the address and postcode of Person 2.

Person 2 Address:

Person 2 Postcode:

Person 2 Relationship to the Child/Young Person

Person 2 Email:

Person 2 Phone Number:

Please confirm whether person 2 has:

Legal responsibility?:

Yes

No

Consented to the referral?:

Yes

No

Any further members of the household (siblings) or extended family of importance outside the family home:

Please provide details of any relevant family history (including mental health):

If you are concerned that there is a risk to the life of a child or young person call 999 Otherwise, please visit the CAMHS website for contact information, including urgent or crisis support via https://cypf.berkshirehealthcare.nhs.uk/contact-us/

What is the main reason you are asking for support?:*

If Other, please provide details

How long have these difficulties been presenting? (eg: 3 months):*

Please explain: How do the concerns present at home/school/other? Have concerns affected daily life, if so how? Is self-harm present (now/previously)? Have thoughts of not wanting to be alive been identified? Has a specific trigger been identified? Are activities being avoided?:*

Please indicate any relevant and significant life events (i.e. bereavement, trauma, family matters, etc) with appropriate information:*

Young Person's view: please explain how you feel, what you hope for the future and preferences for support:*

Is there any additional information relevant to the referral?:

Is the person completing this different from named person 1 or 2 above?:*

Yes

No

If Yes, please complete the fields below.

Relationship to the child/young person:

Name:

Job Title (if relevant):

Agency (if relevant):

Contact Phone Number - please include dialling code, without any spaces:

Is there a preferred time (between the hours of 9-5 Monday to Friday):

Can we leave a voicemail?:

Yes

No

Email Address:

Please complete the captcha

Wokingham Emotional Wellbeing Hub (EWH) / Mental Health Support Team (MHST) Referral Form

Consent / GDPR

Child/Young Person Details

Parents/Carers/Other Members of the Household

Reason for Referral

Referrer Details