We recommend that you complete this form while logged into a private computer which only you have access to.
Important! Please give your legal name as registered with your GP.
The more ways we can contact you, the faster we may be able to process your request for service.
Is this the person you live with?
Please let us know why you'd like 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 you.
Please describe any mental health difficulties you might be having, e.g. worries, sadness, anger, changeable moods or feelings, self-harm etc.
How long have these been affecting you?
What impacts have these had on you, and have these had any impact on your family, school work or friends?
Please tell us:
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 you have any concerns about eating?
Are you currently working with, or have you worked with, any other agencies, people or organisations, including your 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.