Child and Adolescent Mental Health Service (CAMHS)

Ealing CAMHS
1 Armstrong Way
Southall
UB24SA
Tel: 020 8354 8160
Fax: 020 8354 8391 / Hammersmith & Fulham CAMHS
48 Glenthorne Road
Hammersmith
London
W6 0LS
Tel: 020 8483 1979/77/40/44
Fax: 020 8483 1941
Office Mobile: 07792 782924 / Hounslow CAMHS
Heart of Hounslow Centre for Health
92 Bath Road
Hounslow
TW3 3EL
Tel: 020 8630 3237
Fax: 020 8630 3267
Referral form

Please complete this form and send it to your local CAMHS.

Urgent referrals should be faxed.

We are required to register the full postcode, GP details and NHS number of all referrals. Please include this information in your referral.

Child/Young Person and Family Details:

Child/Young Person’s Name:
Address:
Postcode: / Home Telephone No:
Date of Birth: / Young Person’s Mobile No:
NHS No: / Gender:
Language spoken at home: / Is an interpreter required:
Yes /No
Name of Parents/Carers (whom child/young person lives with):
Relationship to Child: / Work/Mobile No:
Who holds parental responsibility?
Name and Address of GP:
Name and Address of School/College/Workplace:
/ Telephone No:
Telephone No:
Who else lives in the referred child’s/young person’s household?Please list.
Name and relationship to child/young person / Age / School/Occupation

Reason for Current Referral(continue on separate sheet if required)

Please indicate what is required from our service.
Please provide details of significant history, concerns and any risks
Please list any other agencies currently involved/ involved in the past with the child/young person/family;and any services for which they are on a waiting list, and attach any relevant reports / Telephone No:
  1. Do the parents/carers (who have parental responsibility) consent to this referral?

Yes No

If 16 or over, has consent been given by the young person? Yes No

  1. Has the child/young person/family had previous involvement with this or any other

CAMHS?

Yes No Unsure

If Yes: Date ______Reason: ______

  1. Has the child/young person ever been on the Child Protection Register?

Yes No Unsure

If Yes: Date ______Reason: ______

  1. Is the child/young person/family currently involved in Legal Proceedings relating to the child/young person? Yes No

If Yes, please give brief details:

______

______

  1. Are you aware of any domestic violence issues in this family?

Yes No Unsure

If Yes, please give brief details:

______

______

  1. Are there any other matters, such as culture, language, illness, religion, or disability,

which we may need to consider when getting in touch with the family?

______

______

Referrer Details

Name of Referrer: / Profession:
Address:
Postcode: / Telephone No:
Signature: / Date:

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