Referral made by professionals

This form should be completed while logged into a secure work computer which only you have access to.

Important: If the referral is urgent, please call the relevant CAMHS service in addition to submitting the referral online.

Consent

No referral can be accepted without the consent of the child or their parent/guardian. Please select applicable consent.

Consent given by A response concerning consent is required

Child or young person's details

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

Young person's legal first name(s) First name is required Sorry, you entered invalid characters

Young person's legal last name(s) Last name is required Sorry, you entered invalid characters

Family name if different to theirs Sorry, you entered invalid characters

Date of Birth (DD/MM/YYYY) Date of Birth is required Enter date in DD/MM/YYYY format

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

Child or young person's contact information

Phone and email

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

Preferred contact number A phone number is required Invalid phone number. Use # for extension.

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

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

Postal address

Address Postal address is required

Town Town is required You entered invalid characters

County County is required

Postcode Postcode is required Enter a valid postcode

Child or young person's background

Ethnicity Ethnicity is required

What gender does the young person identify with? A response to the gender identity question is required

First language

Is the young person a carer for a family member?

Yes

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

Is the young person a Looked After Child (LAC)?

Yes

Tell us whether the young person is a Looked After Child (LAC)

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

Yes

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

GP details

Young person's GP The GP name is required Sorry, you entered invalid characters

GP contact details GP contact details are required

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

Education

Is the young person in education or training (including home schooling)?

Yes

Tell us whether the young person is in education or training

About the principle parents / main carers (expandable)

Tick box if there is no current main carer

First name The carer first name is required Sorry, you entered invalid characters

Last name The carer last name is required Sorry, you entered invalid characters

Relationship to the young person The carer relationship is required

Address A carer address is required

Tick box if address is the same as the young person's

Phone number A carer phone number is required Invalid phone number. Use # for extension.

Email address A carer email address is required Please enter a valid email address

Does this person have parental responsibility?

Yes

Please state whether the carer has 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 are making this referral, 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 the young person.

Please describe any mental health difficulties they might be having, e.g. worries, sadness, anger, changeable moods or feelings, self-harm etc.