Core-Child and Adolescent Mental Health Service

E-REFERRAL FORM

For referral guidance please refer to the C-CAMHS Referral Guidance Booklet available online at:

Please complete and returnBY EMAIL to:

Bournemouth & Christchurch:
/ East Dorset & Purbeck:

North Dorset:
/ Poole:

West Dorset:
/ Weymouth & Portland:

ClientInformation:

Name of Referred Child/Young Person**: / Date of Birth: / Male / Female:
Current Address:
Postcode: / Home Telephone*: / Contact Mobile No*:
*Main contact number is required if both are not known
Ethnicity: / NHS Number:
Name and address of school/college:
Name and address of GP (if referral received from another source):

Parent/Guardian/Carer Information:

Who does the young person live with?
NAME:
RELATIONSHIP:
PARENTAL RESPONSIBILITY: Yes/No/Not known
If no: who has PR for the CYP: / Current contactnumber:
(if different from above) / Ethnicity:
(Mandatory)

Other Family Members(if known):

Name: / Relationship: / Age (if known): / Male / Female:

Referrer Information:

Name of Referrer:
Job title:
Address: / Tel No:
Fax No (if relevant):
Have you met the child/young person that this referral relates to:

YESNO
Has the child/young person agreed to this referral?

YESNO
We would not accept a referral if you have not met with the CYP prior to making a referral. If you have not met the CYP please provide details as to why:
Is the parent/carer of the CYP aware of this referral being made?

YES NO
If no, please say why not:
Who should correspondence be addressed to? (i.e. carer and child, mother and child, father and child, parents and child, other):
Reason for your referral to C-CAMHs (to include requests of the service):
IMPACT of current difficulties / Yes/No / Supporting evidence
Have the difficulties in emotional wellbeing been present for 3 months or more OR a dramatic change in mood or behaviour has been evident more recently (<4wks) / Yes
No
Is there evidence to show that the difficulties are having a definite, noticeable and ongoing impact on the child/young person’s functioning? / Yes
No
Is there evidence that the difficulties are present in two or more areas of functioning: e.g. school, home, leisure and social situations? / Yes
No
Are the difficulties worsening/persisting despite interventions being in place e.g. ELSA in school, community parenting support, GP directed self help? / Yes
No / (Please provide details of support provided to/accessed by the CYP/family to date. If no services have been accessed please state reason why)
CONTEXTUAL factors of note / Yes/No / Supporting evidence
Is there evidence of difficulty (acute or chronic) within the family system e.g. parental mental health issues, maltreatment, social deprivation, social isolation, family trauma? / Yes
No
Is there evidence of past or current external stressors e.g. family breakdown, traumatic events, bereavement, exams, hospital visits (past or impending)? / Yes
No
Are there concerns of risk that is ongoing e.g. domestic abuse, physical chastisement, significant substance use, exploitation, risks posed by significant others? / Yes
No
Is the CYP an unaccompanied asylum seeker (UASC)? / Yes
No
If there are TWO or more contextual factors highlighted above, please confirm the following:
YES / NO
Safeguarding processes are in place and/or a referral has been made to the MASH: / /
Parent/carer support is available and/or parents/carers are engaged already or willing to engage: / /
Where there are enduring risk factors present, a chronology of events has been written: / /
Is the Child subject to a Child Protection Plan?

PREVIOUS CURRENT N/ACATEGORY______

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Additional risk factors relating to the CYP:

Yes / No / Not known
Significant/recurrent self-harm / / /
Suicidal ideation / / /
Child Sexual Exploitation (CSE) / / /
Risk towards others (Please give detail) / / /
Difficult to Engage / / /

Care Status:

Looked after? (i.e. under care of Local Authority)

YES NO
(e.g. foster/residential care or adoption) / Has a CAF been completed? (If yes, please attach)

YES NO

Other agencies involved:

Yes / No / NAME/ADDRESS/CONTACT NUMBER
Homestart or Portage / /
Connexions / /
Children’s Centres / /
Educational Psychology / /
Autism Wessex / /
Substance Misuse Services / /
Paediatrics/Child Health / /
Social Care / /
School Health Team (nurses) / /
Family Partnership Zone / /
YOT / /
Action for Children / /
Other / /

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