NEL CAMHS CORE TEAM
REFERRAL FORM
Referrer’s Details
Has referrer obtained parental consent to contact CAMHS? YES/NO
Referrer’s Name......
Designation Address ………….…………………………......
…......
Tel No......
Child/Young Person’s Details
Name …………………………………………Sex M/F DOB…………..…..
NHS Number ………………………………......
Address …………………………………………………………………………
………………………………………Post Code ……………………………….
In your opinion, is it safe to do a home visit?Yes/No
If no, document any risks
…………………………………………………………………………………………
…………………………………………………………………………………………
Ethnicity …………………Religion/other beliefsystems......
School ………………………………………………DFE code …….………......
Parent/Guardian’s Details
Name(s) ………………………………………………………………………...
Address
(If different from above) ……………………………………………………....
………………………………………………Tel No …………………………...
GP Details
Name ……………………………………………………………………………
Practice/Address ……………………………………………………………….
…………………………………………….. Telephone No ……………………
Family Details(all who live in same residence)
Additional Information
Looked after child*Yes/No
IfYes which Local Authority?
Please state______
Learning disabilityYes/No
Learning difficultyYes/No
Young carerYes/No
Attempted suicideYes/No
Involved with NESTYes/No
Attending a Pupil Referral UnitYes/No
Involved with YOSYes/No
Child Protection
Never been subject to CPYes/No
Has previously been subject to CPYes/No
Is currently subject to CPYes/No
Not knownYes/No
REFERRAL DETAILS PRIMARY PRESENTING PROBLEM
Please describe the problem; identifying specific mental health concerns (include when it started and how long it has been an issue).
To what extent is this impacting on the young person’s life and functioning? (i.e. what’s changed?)
What has been done to address the difficulty and have any other interventions been tried (i.e. school counselling, parenting support etc)?
What are the associated risks?
Risk Factors / Yes / No
/ If Yes, please comment
Self-harm / Please include details of self-harm (i.e. history of self-harm, type of self-harm, how often and most recent occurrence)
Suicidal thoughts / Please include any thoughts, plans or intent for suicide
Has there been a close friend or family member who has committed suicide? (who and when)
Is there a history of family psychiatric hospital admission? (who and when)
*Harm to others / Please specify who is at risk
*Harm from others / Please consider risk of Child Sexual Exploitation, Parents with a history of violence
* Please report safeguarding concerns to NE Lincolnshire Children’s Services
Other agencies involved with this child/young person
Outcome (for CAMHS use only)
Please post to
CAMHS Core Team
Freshney Green Primary Care Centre
Sorrel Rd
Grimsby
DN344GB
Telephone: 01472 626111 (Advice Line for professionals only) / 01472 626100 (General Enquiries) / 01472 358957 (Fax Number)
Email: