About you

Important! Please give your legal name as registered with your GP.

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

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

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

Gender Please tell us your gender

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

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

Contact information

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

Postal address

Address Your postal address is required

Town Your town or city is required You entered invalid characters

County Your county is required

Postcode Your 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

Your background

Ethnicity Ethnicity is required

Languages spoken

Are you a carer for a family member?

Yes

No

Tell us whether you are a carer for a family member

Are you a Looked After Child living with foster parents or living in a residential children's home?

Yes

No

Tell us whether you are a Looked After Child

Do you have a family member serving in the military or who is ex-military?

Yes

No

Tell us whether you have a family member serving in the military or who is ex-military

Healthcare

Your doctor (GP) 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 you in education or training (including home schooling)?

Yes

No

Tell us whether you are in education or training

About your parents / main carers

Tick box if you do not have a carer

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

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

Relationship with you Please tell us their relationship with you

Address A carer address is required

Tick box if their address is the same as your'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 for you?

Yes

No

Please state whether the carer has parental responsibility

Is this the person you live with?

Yes

No

Please state whether this is the person you live with

Add more details

Reason for referral

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.