Refer someone to CAMHS

Please do not send the referral form to your patient to complete. We do not accept self-referrals.

Referrer information

Referrer name *

Job title *

Address

Tel no

Email address *

Have you met the child/young person that this referral relates to? *

Has the child/young person agreed to this referral? *

Is the parent/carer of the CYP aware of this referral being made? *

Please say why not

Client information

Name of referred child/young person *

Current address *

Home telephone *

Date of birth *

Male / Female *

Contact mobile Number *

Ethnicity *

NHS number *

Name and address of school/college *

Name and address of GP (if referral received from another source) *

Parent/guardian/carer information

Name *

Current contact number *

Relationship *

Ethnicity *

Parental responsibility *

Who has PR for the CYP

Other family members (if relevant to this referral)

Please provide name, relationship, age and male/female

Reason for referral

So that we can best understand the clinical needs of the CYP, please also provide details about the impact of the difficulties (e.g. increased risk to self), and information about what support is currently in place/has been offered e.g. online, community or school based resources. *

Please describe your concerns about the child/young persons mental health and social wellbeing that have led to this referral being made, and what you are requesting from C-CAMHs. (Please include information on how long the difficulties have been present, in what settings the difficulties are evident, and what support/strategies have been tried so far).

Risk factors relating to the child/young person

Significant/recurrent self-harm

Suicidal ideation

Child Sexual Exploitation (CSE)

Please highlight the CSE risk concerns

Risk towards others

Please give detail

Difficult to engage

Care status

Looked after? (i.e. under care of Local Authority)

Has an Early Help Assessment (EHA) been completed?

Local authority involvement

Please outline any current involvement from social care in relation to the child/young person or family and/or if there are any current contextual factors that would be useful for us to know e.g. parental mental health needs, social risk factors (e.g. unemployment), additional physical health needs, maltreatment or exploitation. *

Refer someone to CAMHS

If you need urgent mental health support, visit Access Mental Health.