CAMHS self-referral form

This CAMHS Gateway self-referral form is for 16-17 year olds in Dorset.

Title Required

First name Required

Last name Required

Date of birth Required

Gender Required

Phone number Required

Can a voicemail be left on this number? Required

Can an SMS be sent to this number?

Email Required

Address Required

Address 1

Address 2

City

Country

County

Postal Code

GP surgery Required

GP surgery address Required

School Required

School address

Parent/carer information

Name Required

Phone number Required

Is your parent/carer aware of your self-referral to CAMHS?

Would you like an interpreter present for your assessment?

Please note: If we have concerns relating to risk and are unable to contact you, we will contact your parents/carer.

Demographic details

Sexual orientation Required

Nationality Required

Religion Required

Ethnicity Required

Disabilities Required

Please give details of any accessibility requirements e.g. easy-read or large print information:

Please tell us the reason for your self-referrals and give us an outline of the main problem that you are having difficulty with Required

Background Information

Other help you've tried or been offered

So that we can know more about what other help you've tried/been offered, please tell us who else you've contacted, or what other services you've seen so far

I've used some apps on my phone

I've read some books about what I'm going through

I've looked at some websites that have been helpful

I speak to teachers and other staff at my school

I/my family have had some help from:

Connection

Children's Centres

Educational Psychology

Autism Wessex

Dorset MIND

Substance Misuse Services

Paediatrics/Child Health

Social Care

School Health Team (nurses)

Family Partnership Zone

Can you say any more about this?

Youth Offending Team

Young Persons Eating Disorder Service

Other

Action for Children

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Refer someone to CAMHS