CAMHSCONFIDENTIALREFERRAL FORM

Have you already discussed this referral with CAMHS Professional Advisory Service? YES / NO

If not, please consider ringing first on 0116 295 5048 (Mon-Fri, 10.30am-2pm) as it may save you time and effort.

PLEASE NOTE ALL SECTIONS MUST BE COMPLETED
REFERRALS RECEIVED WITH INSUFFICIENT INFORMATION WILL BE RETURNED TO REFERRERS FOR COMPLETION, PRIOR TO THEM BEING CONSIDERED BY CAMHS FOR ASSESSMENT.
PLEASE SEE ATTACHED REFERRAL GUIDE

General Information of referred child/adolescent:

Surname: ______Surname of Parent / Carer: ______
(if different from child)
First Name/s:_______Date of Birth: ______
Male / Female * (*Circle as appropriate) NHS Number: ______
Family Relationships e.g. parent / carer, siblings

Surname

/ Forename / DOB / M/F / E/O (see over for codes) / Religion / Relationship to subject
Current Address: ______
______Postcode: ______
Telephone No’s Home ______Work ______Mobile ______
Name of person/s with parental responsibility: ______
Address and telephone number /s of the person/s with parental responsibility if different from above:
______
______Postcode: ______
Relationship to referred child: ______
Does the child/adolescent or accompanying parent have a disability that requires support arrangements to be provided? Yes / No If so please specify:
Is the child/adolescent/family aware that this referral has been made? ______
Legal Status: ______Ethnic Category (see list of codes)
Name of school attended by referred child: ______
Name and address of GP: ______
______
______Postcode: ______
Details of Referral:(see Referral Guide)
Your assessment of the child / young person’ mental health symptoms
______
______
______
______
______
______
______
______
Medical History / Medication:______
______
Additional information you think we should be aware of : ______
______

Any other services involved (Social Worker, Educational Psychologist (with names and contact numbers, if known)?-

Is the child an overseas visitor? Yes / No Will the child/family require an interpreter? If Yes what language

Referrer’s Details:

Name (please print) ______

Job Title: ______

Address: ______

______

Signature ______Date ______

Ethnicity Codes

1 Asian or Asian British

/
2 Black or Black British
/ 3 Chinese / 4 Mixed /
5 White
/ 6 Other Ethnic Origin / 7 Not Stated
a Bangladeshi / a African / a Asian & White / a White British / a Not asked
b Indian / bCaribbean / b Black African & White / b White Irish / b Refused
c Pakistani / c Other Black Origin / c Black Caribbean & White / c White Other
d Other Asian Origin / d Other Mixed Origin

Once completed send this form to:

IF CHILD IS REGSITERED WITH CITY GP
Child and Adolescent Mental Health Service
SPA Team
Westcotes House
Westcotes Drive
Leicester
LE3 0QU
Fax: 0116 295 2899 / IF CHILD IS REGISTERED WITH COUNTYGP
Child and Adolescent Mental Health Service
SPA Team
Valentine Centre
GorseHillHospital Site
Anstey Lane
Leicester
LE7 7GX
Fax: 0116 295 3338

WHAT MAKES A GOOD REFERRAL

Guidance on Referral to CAMHS

Who Can Refer

At present, referrals are accepted from GPs, hospital and community doctors, social workers and education psychologists. Other professionals in health services may refer only in conjunction with the GP.

Advice

Referrers are invited to telephone the CAMHS Professional Advisory Service to discuss possible referrals. Telephone: 0116 295 5048, Monday – Friday, 10.30am – 2.00pm.

General Considerations

  • Have you met with the parent(s)/carer(s) and the referred child/young person? All young people should be seen and assessed by the referrer.
  • Has the referral to our service been discussed with the parent(s)/carer(s) and the referred child/children? Parents/ carers and young people should be informed about the service and have given explicit consent to the referral.
  • The information we request on the form is required to ensure that we meet adequately and fairly identify the needs of the referred person.
  • Please include ethnicity and indicate if there are any communication problems e.g. linked to deafness or where English is not the first language, so that arrangements can be made for interpreters.

Information Required

We would be grateful if you could consider the following points and questions when making a referral to the Child and Adolescent Mental Health Service.

  • Your own assessment of the problem / issues and level of risk.
  • What are the specific difficulties that you want our service to address and any changes from previous presentation.
  • Any identified precipitants or triggers.
  • Developmental history, if applicable.
  • How is this impacting on

-Family life, interactions at home.

-School, interactions with teachers / peers

-Leisure / social activities

  • Any significant family history, including physical or mental health issues.
  • Any illicit substance use or alcohol abuse.
  • Other services who have been or are currently involved.

PLEASE SEE OVER FOR MORE SPECIFIC INFORMATION

SPECIFIC INFORMATION :

ADHDContext, do symptoms occur across one, two or all settings of family life, school, leisure/social activities?

Impact (excessive risk taking, impaired interpersonal relationships with teachers, parents, peers, etc)?

Any acts of aggression?

Any learning disabilities?

Associated psychiatric symptomology.

Interventions already tried.

ANXIETYIn what context is the anxiety most likely to occur?

If there are panic attacks, when and how often?

ASDObsessional difficulties, in what context?

Language/communication difficulties?

DEPRESSIONFluctuations in mood?

Changes in sleeping/eating patterns?

Changes in attention/concentration?

Significant weight loss/gain?

Evidence of tiredness, loss of energy?

Degree of self-care?

Risk or actual self-harm/suicidal ideation?

EATING

DISORDERSWeight/height at onset of problem and at last appointment with GP?

Blood test results?

Menarche & LMP?

Changes in mood?

Obsessive features?

Exercise?

Any evidence of restricting food/binge eating?

Please specify details of any self induced vomiting/use of laxatives and/or diuretics (onset, when, duration, frequency, any other information)?

Risk or actual self-harm suicidal ideation?

Evidence of other psychiatric symptomotology, e.g. anxiety?

OCDRituals or repetitive behaviour(s)?

Evidence of anxiety?

Fluctuations in mood?

PSYCHOSISEvidence of hallucinations (perception of voices being heard that no-one can account for or seeing things which others cannot see)?

Evidence of thought disorder (confused thinking, poor concentration)?

Evidence of delusions (odd, firm, fixed beliefs which cannot be reasoned away)?

Changes in mood (excitability, irritability, being aloof or withdrawn)?

Risk of self-harm/suicidal ideation?

Degree of self-care?

SELF-HARMINGType of self-harm?

Frequency?

Severity?

Sites of self-harm (and what form)?

Mood?

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