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 Required

Job title Required

Address Required

Address 1

Address 2

City

Country

County

Postal Code

Phone number

Email address Required

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

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

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

Please say why not

Will the child/young person need an interpreter present for the assessment?

Client information

Name of referred child/young person Required

Current address Required

Address 1

Address 2

City

Country

County

Postal Code

Home telephone Required

Date of birth Required

Gender Required

Contact mobile Number Required

Ethnicity Required

NHS number Required

Name and address of school/college Required

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

Parent/guardian/carer information

Name Required

Current contact number Required

Relationship Required

Ethnicity Required

Parental responsibility Required

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 Required

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)

Risk towards others

Difficult to engage

Care status

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

Has an Early Help Assessment (EHA) been completed?

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. une Required

I agree to the privacy policy

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CAMHS self-referral form