Parent / carer referral
This form is for a parent or carer making a referral on behalf of a child or young person.
We recommend that you complete this form while logged into a private computer which only you have access to.
Young person's contact information
Do you give consent for us to send mail to this address?
Young person's background
Reason for referral
Please let us know why you'd like them to be seen by CAMHS, including details of any previous or current mental health problems.
The more information you include, the better we can decide on how best to help them.
Please describe any mental health difficulties they might be having, e.g. worries, sadness, anger, changeable moods or feelings, self-harm etc.
How long have these been affecting them?
What impacts have these had on the young person, and have these had any impact on their family, school work or friends?
Please tell us:
- Impacts on them: e.g. sleep, appetite, motivation, self care, etc.
- Impacts on relationship with those around them.
- Are they still communicating with friends?
Has anything happened recently to make you seek help at this time?
Have there been any big family events or illnesses recently?
Is there any further information that you think we should know?
Please include answers to these questions:
- Do they still go to school?
- What activities do they enjoy doing?
- Are they still motivated?
- Has there been a change to concentration at school?
- Have they thought about harming themself and have they acted on these thoughts?
Do you have any concerns about their eating?
Are they currently working with, or have they worked with, any other agencies, people or organisations, including their school?
I agree to information being shared between agencies.
If you wish to retain a copy of your referral for your own records, please print the page before clicking Submit.