Risk section
For health professionals only
Please indicate all areas of risk identified (healthcare professionals only)
Date of referral
* Required
Date
Priority
Please give an overview of the concerns for the person being referred
* Required
Please indicate any dates that are not convenient for assessment or appointments
Child/young person's details
Full name
* Required
Date of birth
* Required
Date
NHS number
* Required
Gender identification
* Required** None Male Female Non-binary Transgender Prefer not to say
Ethnicity
* Required** None White - British White - Irish White - any other background Mixed - white and black Caribbean Mixed - white and black African Mixed - white and Asian Mixed - any other mixed background Asian or Asian British - Afghani Asian or Asian British - Arabic Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Indian Asian or Asian British - Iranian Asian or Asian British - Iraqi Asian or Asian British - Japanese Asian or Asian British - Pakistani Asian or Asian British - Tamil Asian or Asian British - any other Asian background Black or black British - African Black or black British - Caribbean Black - any other black background Other ethnic group - any other group not listed I do not wish to state Unknown
Address
* Required
Preferred phone number for contact
Mobile phone number (if different)
Email address
Do you need an interpreter?
** None Yes No
If you need an interpreter, which language?
Main spoken language at home
Do you have any physical or communication impairments that may mean you need assistance arranging appointments?
** None Yes No
If you need assistance, please give us some more details about your impairment(s) and needs so we can best support you
Referrer details
To be completed by the person making the referral on behalf of the young person.
Name
GMC
Organisation
Organisation code (if applicable)
Phone
Address
Fax
Email (NHS)
GP details
Only required if the referrer is not the patient’s GP
Name
Job title
Surgery address
Phone
Fax
Email
Name(s) of parents or carers
Relationship to child
Contact number
Email
Who holds parental responsibility? (parent/carer/Local Authority (LAC)
Name
Address
Phone
Email
Please list the names, age, relationship to the young person being referred, and the school/college/university attended, or occupation of each person in the household
Please give details of the young person's school, college or work place
Name of school, college or workplace
Address
Phone
Reason for referral
Please provide us with as much information as you feel relevant to help us deal with the referral efficiently.
Please provide details of significant history, concerns and any risks
Past medical history - include only relevant medical history
Are there any other agencies currently involved or who have involved in the past with the young person/family; and any services for which they are on a waiting list?
Physical health assessment
Date of physical examination
Date
Allergies
Weight (please indicate whether stones and lbs or kilos)
* Required
Height (metres)
* Required
Medication
Please list all medications including: Name of medication, dose, who it was prescribed by or where obtained, duration.
Accute medication - used in the last month
Ongoing (repeat) medication
Further information
Do the parents/carers (who have parental responsibility) consent to this referral?
Has the child/ young person/family had previous involvement with this or any other CAMHS?
If yes, please give dates and reason
Has the child/young person ever had a Child Protection Plan?
If yes, please give the date and circumstances
Is the child/young person/family currently involved in legal proceedings relating to the child/young person?
If yes, please give brief details
Are you aware of any domestic violence issues in this family?
If yes, please give brief details
Are there any other matters, such as culture, language, illness, religion, or disability that we may need to consider when getting in touch with the family?
