About the young person

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

Legal first name(s) Their first name is required Sorry, you entered invalid characters

Legal last name(s) Their last name is required Sorry, you entered invalid characters

Family name (if different) Sorry, you entered invalid characters

Gender Please tell us their gender

Date of Birth (dd/mm/yy) Please tells us their date of birth Enter date in DD/MM/YYYY format

NHS Number (if known) NHS Number should be 10-digits

Young person's contact information

Their current address Their postal address is required

Town Their town or city is required You entered invalid characters

County Their county is required

Postcode Their postcode is required Enter a valid postcode

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

Yes

No

Please state whether you give permission

Young person's background

Ethnicity Ethnicity is required

Languages spoken

Is the young person a carer for a family member?

Yes

No

Tell us whether the young person a carer for a family member

Is the young person a Looked After Child living with foster parents or living in a residential children's home?

Yes

No

Tell us whether the young person is a Looked After Child

Does the young person have a family member serving in the military or who is ex-military?

Yes

No

Tell us whether the young person has a family member serving in the military or who is ex-military

Healthcare

GP Practice The GP name is required Sorry, you entered invalid characters

Contact details (if known)

Health Visitor/School Nurse (if known) Sorry, you entered invalid characters

Education

Are they in education or training (including home schooling)?

Yes

No

Tell us whether they are in education or training

About you, the referrer

First name Your first name is required Sorry, you entered invalid characters

Last name Your last name is required Sorry, you entered invalid characters

What is your relationship with the young person you are referring? Please tell us their relationship with you

Address A carer address is required

Tick box if your address is the same as theirs

Phone and email

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

Preferred contact number (this is the number we will call you on to discuss your referral). A phone number is required Invalid phone number. Use # for extension.

Do you give us permission for us to leave a message on this number? This will include if another person answers your phone.

Yes

No

Tell us whether you give permission

Alternative contact number An alternative contact number is required Invalid phone number. Use # for extension.

Do you give permission for us to leave a message on this number? This consent will include if another person answers your phone.

Yes

No

Tell us whether you give permission

Tick box if no alternative contact number

Email address An email address is required Please enter a valid email address

Tick box if no email address

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

Yes

No

Tell us if they are aware

If 'No', please state the reason why (e.g. age)

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

Yes

No

Tell us if you have parental responsibility

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

Add more details

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.