Information required for this form
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 contact you before we are able to triage the referral
Type of referral
Section one: Young person's details
First name
* Required
Surname
* Required
NHS number
* Required
Date of birth
* Required
Date
Gender identification
* RequiredMale Female Transgender Non-binary Unknown
Ethnicity
* RequiredAsian 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 background Mixed - white and Asian Mixed - white and black African Mixed - white and black Caribbean Mixed - any other background White - British White - Irish White - any other background Unknown Other, not listed
Address where child or young person lives
* Required
Phone number
* Required
Email
School or college attended
School or college address
School or college phone number
Is this a special needs school?
Section 2 - Parent, guardian or carer details
Name
* Required
Address
* Required
Phone number that they can be contacted on
* Required
Email
Section 3 - Home situation
Please provide as much information as possible
Where does the child or young person live?
* Required
Main language spoken by family
Main language spoken by young person
Interpreter required?
* Required
If yes to interpreter, which language?
Parental responsibility
Please provide details e.g. parent/carer/Local Authority (LAC) include name and contact details if not already shown above.
Who holds parental responsibility
* Required
Section 4: Disability and communication needs
Learning disability
* Required
Physical disability
* Required
Please give details of learning and physical disabilities here
Section 5 - Referrer's details
Name
* Required
Role
* Required
Organisation
* Required
Organisation code
Phone
* Required
Email
Address
Section 6 - Consent
Please complete this section fully, without this information we will be unable to triage the referral effectively.
Has the child/young person/family had previous involvement with this or any other CAMHS?
Do the parents/carer/guardians (who have parental responsibility) consent to this referral to CAMHS?
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.
If no, are the parents/carer/guardians (who have parental responsibility) aware of this referral?
If the young person is 16 years and over, does the young person consent to this referral to CAMHS?
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?
If the young person is 16 years and over, does the young person consent to this referral being shared with their parents/carer/guardians?
Are there any other matters such as culture, language, illness, religion or disability that we may need to consider when getting in touch?
If you have indicated that there is a learning or physical disability affecting the child/young person or family member that hasn't already been mentioned, please add here
Section 7 - Reasons and background for referral
Reason for referral
* Required
Main concerns and symptoms
* Required
Behaviours and symptoms in different settings
Impact, distress and impairment
* Required
Section 8 - Safeguarding and risks
Is the family known to children’s social services?
* Required
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?
If legal proceedings are ongoing, please give details
Are you aware of any domestic violence or abuse issues in this family?
* Required
Section 9 - Medical history and treatments
Medical history
* Required
Acute medication in the last month
Ongoing/repeat medication
Allergies and sensitivities
Interventions previously tried (individual and/or family)
Section 10 - Any other agencies involved with the child or young person
Please provide any information you may have about other agencies or professionals involved in the care of this child or young person.
Other Professionals involved and reports
Is the child/young person on a waiting list for a service?
Relevant reports attached to this referral?
* Required
If no, please give reasons as this may significantly delay the processing of this referral
