CAMHS (Child and Adolescent Mental Health Service)Email Referral Form for Professionals

Please complete this form, detailing as much information about the young person you are referring as possible, with reference to the referral guidance. If you prefer to write a letter, please ensure it contains all the information requested in this form.

Name of young person: / NHS Number:
Parent/ Carer Name: / Date of Birth:
Address (inc. postcode):
Family Contact telephone number: / Home: / Mobile:
Name of GP:
Address:
GP Contact Number:

Important things to include in any Referral:

Essential: All referrals require a direct assessment of the child or young person by the referrer.

Reason for Referral: Any assessment should contain information about the symptoms of mental health difficulties; including the duration, severity, impact on day to day functioning and the presence of any risk issues such as self-harming behaviour or risk to others.

If the referral is for an Eating Disorder please direct the referral to (see referral criteria for detail)

We would expect that any previous intervention especially if carried out by the referrer is summarised in terms of engagement, motivation, content and outcome.

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If the referral is for an assessment of Autistic Spectrum Disorder (ASD) or Attention Deficit Hyperactivity Disorder (ADHD) it needs to be accompanied by an assessment report from Ladywood outreach team, Behaviour Support team (or independent equivalent e.g. Aspire and / or Education Psychology (see referral criteria for detail)

Risk: Please include details of any concerns around risk through self-harm, suicidality, the child or young person’s physical condition, aggression, vulnerability to exploitation, substance misuse etc.

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Hopes: We would value a statement regarding the child, young person and family’s expectation of CAMHS referral.

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Consent: Where a young person is deemed to have the capacity to consent to & refuse treatment (everyone over 16 unless proven otherwise) their consent needs to have been gained and be clearly documented in the referral.

If the young person is under 16 they may still be referred by a person with parental responsibility even if refusing. However, if they are reluctant detail about how reluctant and their reasons would be helpful.

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Referrer Details:

Signed (electronic signature):
Name: / Date:
Title / Designation:
Contact Number: / Contact email:

The following information is helpful to us if known:

Is an interpreter required? (please circle) YES NO
If yes please state which language:
What school does the young person go to:
Does the young person have any known disabilities? (if so please detail)
Is the young person subject to a child protection plan? If so please name the social worker.
Is the young person a looked after child? / Are they a young carer?

Please return completed form to:

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