We are required to register the full demographic details (including area of residency, GP details and NHS number) of all referrals. Please include this information in your referral otherwise we will need to return this form to you prior to triage.
CAMHS service
* Required
Date of Referral
Date
PRIORITY (see separate guidance)
* Required
Child/Young Person (Patient) Details
First Name
* Required
Surname
* Required
NHS No
* Required
DOB
* Required
Date
Gender
* Required
Ethnicity
* Required
Religion
* Required
Address
* Required
Area of Residency
* Required
Home Tel
* Required
Mobile Tel
* Required
Email
* Required
Status
* Required
Main Language Spoken
* Required
Learning Disability
* Required
Physical Disability
* Required
Interpreter
* Required
GP Name if not referrer
* Required
GP Phone No
* Required
GP Address if not referrer
* Required
GP admin email address if known
* Required
School/College if applicable
* Required
School/College Address
* Required
School/College Phone No
* Required
Special School
* Required
Parent/Carer/Guardian Details
Name
Address
Home or Mobile Tel
Email
Name of Father
Address
Home or Mobile Tel
Email
Name of Carer/ Guardian if applicable
Address if applicable
Home or Mobile Tel if applicable
Email if applicable
Main residence of child/young person
Main language spoken by family
Learning Disability
* Required
Physical Disability
* Required
Interpreter
* Required
Who holds parental responsibility?
(give details e.g. parent/carer/Local Authority (LAC) include name and contact details if not already shown above)
Referrer Details
Name
Role/Title
Organisation
Address
Organisation code if applicable
Telephone No
Email admin (NHS or egress)
Consent
If this section is not completed fully, the referral will be returned to you prior to triage
Has the child/young person/family had previous involvement with this or any other CAMHS
* Required
Do the parents/carer/guardians (who have parental responsibility) consent to this referral to CAMHS
* Required
Do the parents/carer/guardians (who have parental responsibility) consent to this referral to CAMHS being shared with another more appropriate NHS or Local Authority Service? This includes being sent to another Trust such as CNWL.
* Required
If no, are the parents/carer/guardians (who have parental responsibility) aware of this referral?
* Required
If the young person is 16 years and over, does the young person consent to this referral to CAMHS
* Required
If the young person is 16 years and over, does the young person consent to this referral to CAMHS being shared with another more appropriate NHS or Local Authority Service? This includes being sent to another Trust such as CNWL.
* Required
If the young person is 16 years and over, does the young person consent to this referral being shared with their parents/carer/guardians?
* Required
Are there any other matters such as culture, language, illness, religion or disability that we may need to consider when getting in touch.
* Required
If you have indicated that there is a learning or physical disability affecting the Child/Young Person or family member, please specify here:
* Required
Reason for Referral
Reason for Referral
(Please specify why you think a CAMHS assessment is required and what you wish the service to do)
Main Concerns – Symptoms
(Give details about onset, duration, frequency, severity)
Settings (Home, School and Community)
(Neurodevelopmental disorders and other mental health conditions are pervasive across settings – home, school and community. Give details in relation to different settings)
Impact, Distress and Impairment
(Give details of child development, family life, social life, learning/academic performance)
Risk /Safeguarding Concerns
Is the family known to Children’s Social Services?
* Required
If yes give details:
Does the child have an Education, Health & Care Plan (EHCP), Child Protection (CP) Plan, Child in Need (CIN) Plan?
* Required
Is the child/young person a Looked After Child (LAC)
* Required
Is the child/young person/family currently involved in Legal Proceedings relating to the child/young person?
* Required
If yes give details:
Are you aware of any domestic violence or abuse issues in this family?
* Required
If yes give details:
Are you aware of any drug or alcohol issues in this family?
* Required
If yes give details:
Medical History
(Give sufficient details to rule out organic conditions)
Current Acute Medication in last month
Current Repeat Medication
Allergies & Sensitivities
Interventions Previously Tried (Individual and/or family)
(Give details of school, universal/primary/secondary interventions)
Other Professionals Involved
Other Professionals Involved and Reports
(Give details of other agencies involved now or in the past with the child/young person and family)
Please provide the following for each agency:
Agency Name
Named Worker
Address
Tel No
Is the child/young person on a waiting list for a service?
* Required
If yes give details:
Relevant reports attached
* Required
If No, please give reasons as this may significantly delay the processing of this referral:
If Yes, please upload your reports here:
Please state which reports are attached
