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.

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Indeterminate

Male

Female

Missing data (not recorded/not yet known)

NHS Number:*

Ethnicity:

Nationality:

Religion:

First Language

Interpreter Required:

Yes

No

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode*

Tel (Home/Mobile): (If young person is over 13)

Permission to contact by SMS

No

Yes

Permission to leave voicemail

No

Yes

Other Number:

Email: (If young person is over 13)

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

Legal Status of Child/Young Person (In particular, who are the legal parents/guardians):

Is the young person a refugee or asylum seeker?

Yes

No

Parent/Carer First Name(s):*

Parent/Carer Surname:*

First Language:

Interpreter Required?

Yes

No

Contact details (if different from above)

Tel: (Home/Mobile)

Do you consent to receiving text messages:

Yes

No

Tel: (Other)

Email:

Who is the main point of contact for this referral:*

Parent / Carer / Guardian

Young Person

Parent/Carer/Guardian’s relationship to the young person:*

Is the young person adopted:

Yes

No

Previous/Alternative Care Arrangements:

Are any other family members currently being seen or have previously been seen by mental health services? If so, please give details:

Name:

Practice Name:

Practice Address (including postcode):

Tel:

Email:

Name:

School Address (including postcode):

Tel:

Email:

Is extra support being received in education?:

Yes

No

What Level / Nature (if known):

EHCP plan in place?:

Yes

No

EHCP plan applied for?

Yes

No

SENCO / Key worker Name:

SENCO/Key Worker Contact Email:

Would a telephone triage be appropriate for this young person?:

Yes

No

If no, please explain why:

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

Child:

Young Person:

Parent/Carer:

Please give details of specific reasonable adjustments that are required:

Social Care:

School Nursing:

Speech Therapist:

Occupational Therapist:

Psychology and Therapeutic Services:

Community Paediatrics:

Youth Justice:

Other:

Please provide brief details of current services parents are open to:

If any member of the family is subject to a Children’s Safeguarding plan; is known to adult mental health services; is subject to any kind of legal restriction order/s or if you are aware of any relevant court cases either pending or current, please give details:

Has the Parent/Carer/Guardian or the young person (if aged 13 or above) given informed consent for this referral to be made?:*

Yes

No

Does the young person agree to this referral being made?:*

Yes

No

If no, please explain why this is the case:

(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)

Has the young person aged 13 or over given consent for our service to contact their parent/carer/guardian?:*

Yes

No

We will contact the GP and any other referrer into our services, if the young person/carer does not wish the GP/other referrer to be contacted tick here:

Do Not Contact

We will contact the School or College, if the young person/carer does not wish the school/college to be contacted tick here.

Do Not Contact

If there are any safeguarding concerns this may be overridden

Full Name:*

Job Title:

Organisation:*

Team:*

Address (including postcode):

Telephone:*

Mobile:*

Email:*

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.

Date of referral:*

I confirm I am aware:*

I Confirm

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

Anxious/Worry:*

Compelled to do or think things:*

Panic:*

Avoids specific things:*

Repetitive problematic behaviours (Habit problems):*

Low mood:*

Self-Harm (Self injury or self-harm):*

Suicidal Ideation:*

Extremes of mood:*

Behavioural difficulties:*

Poses risk to others:*

Carer/management of children and young people’s behaviour (e.g., management of a child/children):*

Doesn’t get to toilet in time (elimination problems):*

Disturbed by traumatic event:*

Family relationship difficulties:*

Problems in attachment to parent/carer:*

Peer relationship difficulties:*

Persistent difficulties managing relationships with others:*

Does not speak:*

Unexplained physical symptoms:*

Self-care Issues (includes medical care management, obesity):*

Adjustment to health issues:*

Please provide a brief narrative of the young person’s difficulties and impact on their daily functioning (at school, with friends, at home):

Please describe the urgency of the referral and what planning you have done to keep the young person safe:

What is the current plan in attempting to resolve and/or manage the young person’s problems? What has been tried before, what has helped before and what has not? Ideas the family have about what they believe may help:

How long has the young person experienced these difficulties?:

Please indicate if the young person has experienced any of the following events:

Please give further details (including when if known):

How does the young person/family view this referral? What in your view is the young person’s/family’s motivation and ability to engage?:

**Problem Descriptions

None

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.

Mild

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.

Moderate

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.

Severe

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.

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CAMHS- 0-18 years old– Professionals Referral Form

Information About Referred Person

Information about FAMILY MEMBERS

GP Details

SCHOOL DETAILS

SEND CONSIDERATIONS

OTHER AGENCIES INVOLVED: Please specify name/contact details

SAFEGUARDING ISSUES

CONSENT FOR REFERRAL

REFERRED BY

REFERRER

REASON FOR REFERRAL