FIRST POINT OF CONTACT (FPoC) REFERRAL FORM
The First Point of Contact is the single entry point for all OPEN MINDS (CAMHS) referrals.
The First Point of Contact also provides telephone support and guidance. Referrers are invited to phone the First Point of Contact on 01422 300 001 if they would like to discuss a case before submitting a referral.
We would always advise referrers to phone about crisis/urgent cases, or where suitability for OPEN MINDS (CAMHS) is unclear.
Please note that this on-line referral tool is not supported by the Internet Explorer 10 web browser (or older versions of Explorer). Referrers are encouraged to use a more recent web browser such as Chrome.
Please ensure that you are in a position to fully complete the form before starting to enter the referral information as it is not possible to save partially completed versions.
Mental Health Support Team Schools only
Referral already discussed with MHST?:
Yes
No
If YES, which service are you referring the YP for?
FPoC
MHST
If YES please state the name of the MHST practitioner:
About the Young Person:
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
Also known as:
Date of Birth:*
NHS Number:
Gender:*
Male
Female
Other
If Other, please describe:
Preferred pronouns (e.g. she/her):
Please Select A Value...
She/Her/Her
He/Him/His
They/Them/Their
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
Per/Per/Pers
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
Ethnicity:*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Religion:*
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Church of England
Other protestant
Orthodox Christian
Roman Catholic
Other Christian
Muslim
Shi'ite Muslim
Sunni Muslim
Sikh
Jewish
Orthodox Jewish
Buddhist
Hindu
Jain
Parsi / Zoroastrian
Rastafarian
Any other religion
Not stated
Advaitin Hindu
Ahmadi
Amish
Anabaptist
Ancestral Worship
Anglican
Animist
Anthroposophist
Apostolic Pentecostalist
Armenian Catholic
Armenian Orthodox
Arya Samaj Hindu
Asatruar
Ashkenazi Jew
Atheist
Baha'i
Baptist
Black Magic
Brahma Kumari
Brethren
British Israelite
Bulgarian Orthodox
Calvinist
Catholic: Not Roman Catholic
Celtic Christian
Celtic Orthodox Christian
Celtic Pagan
Chinese Evangelical Christian
Chondogyo
Christadelphian
Christian Existentialist
Christian Humanist
Christian Scientists
Christian Spiritualist
Church in Wales
Church of God of Prophecy
Church of Ireland
Church of Scotland
Confucianist
Congregationalist
Coptic Orthodox
Deist
Druid
Druze
Eastern Catholic
Eastern Orthodox
Elim Pentecostalist
Ethiopian Orthodox
Evangelical Christian
Exclusive Brethren
Free Church
Free Church of Scotland
Free Evangelical Presbyterian
Free Methodist
Free Presbyterian
French Protestant
Goddess
Greek Catholic
Greek Orthodox
Haredi Jew
Hasidic Jew
Heathen
Humanist
Independent Methodist
Indian Orthodox
Infinite Way
Ismaili Muslim
Jehovah's Witness
Judaic Christian
Kabbalist
Liberal Jew
Lightworker
Lutheran
Mahayana Buddhist
Masorti Jew
Mennonite
Messianic Jew
Methodist
Moravian
Mormon
Native American Religion
Nazarene Church / SYN Nazarene
New Age Practitioner
New Kadampa Tradition Buddhist
New Testament Pentacostalist
Nichiren Buddhist
Nonconformist
Occultist
Old Catholic
Open Brethren
Pagan
Pantheist
Patient Religion Unknown (Where the PATIENT has not been asked for their RELIGIOUS OR OTHER BELIEF SYSTEM AFFILIATION)
Pentecostalist / SYN Pentacostal Christian
Peyotist
Plymouth Brethren
Presbyterian
Pure Land Buddhist
Quaker
Radha Soami / SYN Sant Mat
Reform Jew
Reformed Christian
Reformed Presbyterian
Reformed Protestant
Romanian Orthodox
Russian Orthodox
Salvation Army Member
Santeri
Satanist
Scientologist
Scottish Episcopalian
Secularist
Serbian Orthodox
Seventh Day Adventist
Shakti Hindu
Shaman
Shinto
Shiva Hindu
Shumei
Spiritualist
Swedenborgian / SYN Neo-Christian
Syrian Orthodox
Taoist
Theravada Buddhist
Tibetan Buddhist
Ukrainian Catholic
Ukrainian Orthodox
Uniate Catholic
Unitarian
Unitarian-Universalist
United Reform
Universalist
Vaishnava Hindu / Hare Krishna
Vodun
Wiccan
Yoruba
Zen Buddhist
Zwinglian
Disability:*
Yes
No
If Yes, please describe:
First Language:*
Interpreter Required?*
Yes
No
Asylum Seeker:*
Yes
No
Address Line 1:*
Address Line 2:
Town:*
County:*
Postcode:*
Email address (for correspondence/letters):
Home Telephone:
Young Person’s Mobile:
Parent / Carer 1 Name:*
Relationship to young person:*
Parent / Carer 1's Mobile:*
Address of Parent / Carer 1: (If different from young person)
Parent / Carer 2 Name:
Relationship to young person:
Parent / Carer 2's Mobile:
Address of Parent / Carer 2: (if different from Parent / Carer 1)
Please state if OPEN MINDS (CAMHS) should write to parents/carers at both addresses:
Siblings: Name(s) / age(s):
Siblings known to OPEN MINDS (CAMHS)?:
Yes
No
Not Known
Consent:
Our normal practice is to contact school staff and other professionals in order to gain a full understanding of the young person’s needs and how they can be met.
By submitting this referral you are confirming that the family and/or young person give their consent to OPEN MINDS (CAMHS) contacting school and any other relevant agencies.
We work in partnership with Public Health and where appropriate we will share referral information with these partners (such as the School Nursing Team) in order to get the right support for the young person.
If the family/young person are not happy to give this consent, or if you have any questions or concerns about this process, please provide further details below or contact the FPOC on 01422 300 001 prior to submitting a referral.
Further consent details:
Have you seen the young person:*
Yes
No
Is the young person aware of this referral:*
Yes
No
Is a Parent / Carer aware of this referral:*
Yes
No
Has the Parent / Carer consented to this referral:*
Yes
No
Does the Parent / Carer have parental responsibility:*
Yes
No
If ‘NO’ then who holds parental responsibility:
Has the person with parental responsibility consented to the referral:*
Yes
No
If ‘NO’ then is the YP deemed to be Gillick competent according to the Fraser Guidelines:
Yes
No
If 'YES' please state how the young person would like to be contacted:
About the Referrer:
Name:*
Job title:*
Agency:*
Address:*
Postcode:*
Telephone:*
Mobile:
In order for us to update you on the outcome of this referral, please share an
email address:
Date of Referral:
Other Agency Involvement:
Please make the young person and/or family aware that we may need to contact some or all of the professionals and agencies named below in order to gather further information and reach an informed decision.
GP:
GP Surgery:*
Name of Doctor:*
Surgery Address:*
Surgery Postcode:*
If applicable, do you have a health visitor involved with your family?
Yes
No
If applicable, please provide the name and contact number of your health visitor.
Nursery/School/College:
Name of Nursery/ School/ College:*
Nursery/ school contact person e.g. class teacher / tutor / SENCO / learning mentor:
Are nursery/ school aware of this referral?:
Yes
No
Not Known
Is there a CAF / Early Help Plan in place?:*
Yes
No
If ‘YES’ please provide the name of lead profession and send us the details according to the instructions at the bottom of this form:
On SEN Support?:*
Yes
No
Not Known
If 'Yes' please provide further detail below, and forward any relevant documentation.
Does the child have a Statement of Special Education Needs/Education, Health & Care (EHC) Plan, or similar?:*
Yes
No
If ‘YES’ send us the details according to the instructions at the bottom of this form, if available.
OPEN MINDS (CAMHS):
Past OPEN MINDS (CAMHS) involvement?:*
Yes
No
If ‘YES’ please give details here, including date / reason for involvement / services seen by:
Have you actioned the recommendations provided when the young person was discharged?:*
Yes
No
If ‘YES’, please provide more details. It is important that you are able to evidence these have been actioned and your current referral may not be progressed if such recommendations remain outstanding:
Safeguarding:
Has the young person ever been deemed a Child in Need:*
Yes Currently
Yes Previously
Never
Not Known
Has the young person ever been subject to a Child Protection Plan:*
Yes Currently
Yes Previously
Never
Not Known
Has the young person / family ever had social work involvement:*
Yes Currently
Yes Previously
Never
Not Known
If ‘YES’, please provide further details. i.e. reason for involvement, dates / length of involvement, name and contact number of any current social worker:
Is the young person in the care of the Local Authority?(CLA - Children Looked After status):*
Yes
No
If ‘YES’, provide detail of the Local Authority responsible for providing care, Social Worker name and contact details:
Other People / Agencies involved in supporting the YP/Family:
Known parental substance misuse:
Yes
No
If 'YES' please provide further details:
Risk Factors:
In the last month has this young person harmed themself or somebody else?:*
Yes
No
If ‘YES’, please give further details, comment on severity / frequency:
In the last month has this young person had any thoughts to end their life?:*
Yes
No
If ‘YES’, please give further details, comment on severity / frequency:
Are there any concerns around a possible eating disorder or psychosis?:*
Yes
No
If ‘YES’, please give further details, comment on severity / frequency:
Any other information relating to risk:
Reason for Referral:
What is the particular issue you are seeking help or advice about? Please give details of emotional or mental health difficulties, when these started, and how the problem is seen at school and at home, what interventions have been tried etc.
REFERRER’S CONCERNS & EXPECTATIONS:*
Please identify any risk factors and specialist needs e.g. safeguarding concerns, poor mobility, sensory impairment, learning difficulties, literacy problems, substance misuse, need for interpreter, parental agoraphobia or risk of violence.
SPECIALIST NEEDS:*
YOUNG PERSON’S CONCERNS & EXPECTATIONS:*
PARENTAL CONCERNS & EXPECTATIONS:*
ANY OTHER RELEVANT REFERRAL INFORMATION:
Primary reason for referral:*
Please Select A Value...
Anxiety
Depression
Conduct disorders
Self harm behaviours
Eating disorders
Self Care issues
Relationship Difficulties
Phobias
Unexplained physical symptoms
Post Traumatic Stress Disorder (PTSD)
Suspected Autism Spectrum Disorder
Neurodevelopmental Conditions (excluding Autism Spectrum Disorder)
Diagnosed Autism Spectrum Disorder
Support from the Learning Disability Team
Other
Please describe any mental health difficulties the young person may be experiencing:
If ASD, ADHD OR ASD & ADHD is selected, please provide further relevant information:
If 'Support from the LD Team’ is selected, please describe (e.g. challenging behaviour, sleep, continence, epilepsy, parenting support):
Additional Documentation:
Do you have any additional documentation that would support this referral?*
Yes
No
If Yes, then please specify the nature of this documentation and how you will be sending it:
Please e-mail the documentation as an attachment to firstpointofcontact@calderdalecamhs.org.uk. Please note - this email address may not meet the security requirements of your organisation. If preferred, post it to OPEN MINDS (CAMHS) First Point of Contact, 9 Clare Road, Halifax, HX1 2HX.
Please note that you may be asked to go back and complete any missing information before the form can be successfully submitted. Please don't close the page until you have received an on-screen message which is confirmation that we have received the referral. The system does not enable us to automatically send you a copy of the referral form but we would be happy to post one to you on request.
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