CAMHS- 0-18 years old– Professionals Referral Form

*For mental health crisis referrals where there is an IMMEDIATE risk to self or others contact 999.
For URGENT advice, signposting and access to crisis response please contact NHS 111 and select the ‘mental health option’.
All the information requested on this form is required to ensure we provide a safe and responsive service. We are therefore unable to accept forms that are not fully completed.
If you are a professional, to ensure that your patients access the correct service in a timely manner, please consult the CAMHS Referral criteria before completing this form.

Information About Referred Person

By giving us your email address, we are assuming that you consent to being contacted in this way.

Information about FAMILY MEMBERS

Contact details (if different from above)

GP Details



Does the Child /Young person / Parent/Carer require any reasonable adjustments?

OTHER AGENCIES INVOLVED: Please specify name/contact details



(It is important that the young person is aware of the referral and agrees that this referral is made as this will have a direct impact on their motivation to engage with our service. There are however certain circumstances where children / young people might not have capacity to consent to the referral)
If there are any safeguarding concerns this may be overridden



I am aware that there are delays between referral and assessment and agree to continue to provide oversight of the patient’s care and treatment where appropriate and consider this delay when planning care and support during this period. This will include creating a safety plan with the patient, family and their network.


Completion of the below questionnaire will greatly assist us in determining the young person’s needs and what service they require. Please draw on all the information you have available to you regarding the child/young person’s difficulties and tick as appropriate, however incomplete this may be. This Section can be completed by or in conjunction with parent/carer/young person and MUST accompany the referral. Please refer to CAMHS Referral Criteria.
Full Problem Descriptions can be found at the bottom of this form
**Problem Descriptions
Functioning = There may be transient difficulties and ‘everyday’ worries that occasionally get out of hand (e.g. mild anxiety associated with an important exam, occasional ‘blow-ups’ with siblings, parents or peers) but the child or young person is generally secure and functioning well in all areas (at home, at school, and with peers).
Distress of Young Person = No distress or noticeable difficulties in relation to this problem.
Functioning = Symptoms cause occasional disruption but do not undermine functioning and impact is only in a single context. All/most age-appropriate activities could be completed given the opportunity. The child or young person may have some meaningful interpersonal relationships.
Distress = Distress may be situational and/or occurs irregularly (less than once a week). Most people who do not know the child or young person well would not consider him/her/them to have problems but those who do know him/her/them well might express concern.
Functioning = Functioning is impaired in at least one context but may be variable with sporadic difficulties or symptoms in several but not all domains.
Distress = Distress occurs on most days in a week. The problem would be apparent to those who encounter the child or young person in a relevant setting or time but not to those who see the child or young person in other settings.
Functioning = child or young person is completely unable to participate age- appropriately in daily activities in at least one domain and may even be unable to function in all domains (e.g., stays at home or in bed all day without taking part in social activities, needing constant supervision due to level of difficulties, no longer managing self-care).
Distress = Distress is extreme and constant on a daily basis It would be clear to anyone that there is a problem.
Not Known
this aspect of the case has not yet been adequately assessed by you to make a "none" rating. Do not use this rating when deciding between the other ratings (e.g., between mild and moderate) - just make your best guess between the best ratings.