CAMHS Referral Form

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.

About the young person

Important! Please give the child or young person's legal name as registered with their GP.

   
   
 
 
   
 

Young person's contact information

 
   
 
   

Do you give consent for us to send mail to this address?

 

 

Young person's background

 

 

 

 

Healthcare

   
 

Education


 

About you, the referrer

   
   
 
 

Phone and email

The more ways we can contact you, the faster we may be able to process your request for service.

   

 
   

 
   

Is the young person aware that you are making this referral to CAMHS?

 

Do you have parental responsibility for the young person you are referring?


 

If you wish to add any other information you think is relevant, please tick here.

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?

Eating concerns

Do you have any concerns about their eating?


 

Other professionals

Are they currently working with, or have they worked with, any other agencies, people or organisations, including their school?


 

Information sharing

Oxford Health NHS Foundation Trust delivers a wide range of high quality healthcare services in partnership with many other organisations including the public, charities, voluntary, third party and private sector. To ensure we deliver the best care for our patients without the need to constantly repeat themselves we share only the minimum amount of information required for our partners to provide the continuity of care our patients expect. By engaging with Oxford Health NHS Foundation Trust you consent to your information being shared between our relevant partners as described above. All patient information is held securely, and access is controlled in accordance with the Data Protection Act 1998. Oxford Health NHS Foundation Trust's privacy policy can be accessed here: www.oxfordhealth.nhs.uk/privacy

I agree to information being shared between agencies.

 

Printing

If you wish to retain a copy of your referral for your own records, please print the page before clicking Submit.