PERSONAL DETAILS
Date of Referral
First Name
Surname
Date Of Birth
Gender
Ethnicity
Address
Post Code
Telephone
Email Address
Parent / Carer Name
GP Surgery
School / Work
Referrer:
Name, Agency, Contact Info
CONSENT SOUGHT FOR REFERRAL / FROM PARENT/CARER YES NO
FROM YOUNG PERSON YES NO
CONSENT SOUGHT FOR SECURELY STORING INFORMATION AND SHARING INFORMATION WITH OTHER PROFESSIONALS / FROM PARENT/CARER YES NO
FROM YOUNG PERSON YES NO
LAC / YES NO
CP PLAN / YES NO
(IF YES SEEK PERMISSION FOR COPY)
SOCIAL WORKER’S CONTACT DETAILS
OTHER PROFESSIONALS/ AGENCIES INVOLVED
FAMILY DETAILS – If more than 4 children please add their details below
First Name / Surname / DOB / M/F / Education / Employment
Parent / Carer 1
Parent / Carer 2
Child 1
Child 2
Child 3
Child 4
DURATION OF DIFFICULTIES
1-2 weeks
Less than a month
1-3 months
More than 3 months
More than 6 months

Please tick the appropriate boxes to give us a view of the young person’s mental health needs.

REFERRAL ISSUES
Anxiety
Transition issues
Bullying
Sexual identity issues
Bereavement
Gender identity issues
Conflict with parents
Past sexual abuse
Children whose parents have a MH, drug and/or alcohol issue
Panic attacks (overwhelming fear, heart pounding, breathing fast etc.)
Changes in mood (low mood –sad, apathetic; high mood –exaggerated / unrealistic elation)
Sleep disturbance (difficulty getting to sleep or staying asleep)
Eating issues (change in weight / eating habits, negative body image, purging or binging)
Difficulties following traumatic experiences (e.g. flashbacks, powerful memories, avoidance)
Hyperactivity (levels of overactivity & impulsivity above what would be expected; in all settings)
Psychotic symptoms (hearing and / or appearing to respond to voices, overly suspicious)
Delusional thoughts (grandiose thoughts, thinking they are someone else)
Depressive symptoms (e.g. tearful, irritable, sad)
Obsessive thoughts and/or compulsive behaviours (e.g. hand-washing, cleaning, checking)
Autistic Spectrum Disorder
Oppositional Defiant Disorder
Soiling / Enuresis
ADHD
Looked After Child

Impact of above referral issue on young person –please circle below

Little or none / Some / Moderate / Severe
INVOLVEMENT WITH CAMHS
Current CAMHS involvement
Previous history of CAMHS involvement / - Less than 6 months ago
- More than 6 months ago
Consent to receive discharge summary from CAMHS
Previous history of medication for mental health issues
Any current medication for mental health issues
Developmental issues e.g. ADHD, ASD, LD
HARMING BEHAVIOURS
History of self harm (cutting, burning etc)
History of thoughts about suicide
History of suicidal attempts (e.g. deep cuts to wrists, overdose, attempting to hang self)
Current self harm behaviours
Anger outbursts or aggressive behaviour towards children or adults
Verbalised suicidal thoughts* (e.g. talking about wanting to kill self / how they might do this)
Thoughts of harming others* or actual harming / violent behaviours towards others
Social setting - for these situations you may also need to inform other agencies (e.g. Child Protection)
Family mental health issues / Physical health issues
History of bereavement/loss/trauma / Identified drug / alcohol use
Problems in family relationships / Living in care
Problems with peer relationships / Parents involved in criminal activity
Housing Issues / Young Person involved in criminal activity
Not attending/functioning in school / History of social services involvement
Excluded from school (FTE, permanent) / Current Child Protection concerns
Unemployment / History of Domestic Violence

Once complete, please return by email, fax or post to Bromley Y, 17 Ethelbert Road, Bromley BR1 1JA.

If you have any queries when completing this, please call us on 0203 770 8848.

What are the referrer’s hopes for the outcome of this referral?
Brief outline / history of difficulties:

1

Email: ax: 0203 121 3005