CAMHS Referral Form

Make a self-referral

We recommend that you complete this form while logged into a private computer which only you have access to.

About you

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


Contact information

Phone and email

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




Postal address



Your background









About your parents / main carers



Is this the person you live with?


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.


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:

  • Impacts on you: e.g. sleep, appetite, motivation, self care, etc.
  • Impacts on relationship with those around you.
  • Are you 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 you still go to school?
  • What activities do you enjoy doing?
  • Are you still motivated?
  • Has there been a change to concentration at school?
  • Have you thought about harming yourself and have you acted on these thoughts?

Eating concerns

Do you have any concerns about eating?


Other professionals

Are you currently working with, or have you worked with, any other agencies, people or organisations, including your 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:

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.