CAMHS Referral Form /
Please complete fully: insufficient information may lead to the form being returned, resulting in delay
CHILD OR YOUNG PERSON BEING REFERRED
NHS No: / Address:Postcode:
Surname of Child/Young Person:
First Name/s:
Date of Birth: / Male
Female / Mobile No:
Home No:
DETAILS OF PARENT/CARER
Parent/Carer’sFull Name and Relationship to Child:
Name & Address of person with legal parental responsibility (if different from above)
CONSENT
The referrer has gained verbal consent for:
This referral to be made
The sharing of information between professionals and services who are part of the Early Help Hub
Name of person giving Consent:
Date Consent was obtained:
If you feel it is appropriate to submit this referral without consent, please contact the Early Help Hub to discuss this.
Privacy Statement
The information you provide is being collected by Children, Schools and Families Early Help Hub (EHH) for the purpose of helping us to make the right decisions about the type of service you need ensuring you receive services best suited to your needs and circumstances
This information may also be shared with other relevant professionals in conjunction with the nature of the request or enquiry. The data held relating to the delivery of support by EHH to your child will be used both for the provision of services and also for performance and service planning. This information will be held in a secure environment in line with the Information Governance Alliance Records Management Code of Practice for Health & Social Care 2016, upon reaching the relevant retention the information will be appraised and if relevant destroyed in a secure manner. A full copy of our Trust Privacy Notice can be found at
ETHNIC CATEGORY – Mandatory for Completion
British
Irish
Any other White background / White & Black Caribbean
White & Black African
White & Asian
Any other mixed backgrounds / Indian
Pakistani
Bangladeshi
Any other Asian background
Caribbean
African
Any other black background / Chinese
Any other categories
Not stated
If aged 16 or over: is the young person married? / Yes
No
EDUCATION DETAILS / DETAILS OF GP
Name and Address of College, School, Nursery or Pre-School provision (if not in education state occupation): / Name of GP and Practice Address:
CHILD PROTECTION DETAILS
Is the child subject to a Child Protection Plan?
Yes No Unknown
Has the child been subject to a Child Protection Plan inthe past?
Yes No Unknown / Is the Child a “child in care” (e.g. fostered) by the Local Authority?
Yes No Unknown
Has the Child been subject to a Common Assessment Framework (CAF)?
Yes No Unknown
SPECIAL REQUIREMENTS: e.g. Interpreter, Wheelchair Access, etc. Please give details below.
DETAILS / PLEASE OUTLINE MENTAL HEALTH CONCERNS (SEE ELIGIBILITY CRITERIA)Include details regarding onset, duration, severity and effects on family. Relevant History: e.g. Medical, developmental issues and family structure.
DETAILS / Please state what interventions have already been delivered in respect of these difficulties Please note that except in very severe circumstances, other interventions should have been utilised before referral to specialist CAMHS services.e.g. prior to a request for ADHD assessment parents should have engaged in a parenting course and/or educational psychology should have been involved (please list involvement by any other professionals).
A specialist CAMHS team works with children and young people who also have learning disabilities. Does this young person have a moderate or profound learning disability? / Yes
No
Do you need an assessment for ASD (and are there no co-morbid mental health problems or risks?) / Yes
PERSON REFERRING:
Referred by: / Address: / Tel:
Job Title: / Date of referral:
For office use only:
Has this young person been seen previously? Yes No
Date of last contact & with whom:
Brief Details:
Please send completed forms to: email:
Telephone enquiries: 01872 322277 or visit the website