Please Use This Form If You Feel a Child/Young Person Has Additional Needs Which Their

Torbay Child & Adolescent Mental Health Service

(CAMHS) Referral Form

This form should be used in conjunction with the Torbay CAMHS Referral Criteria. Please complete this referral form if you feel a child/young person has a Mental Health need that is having a significant impact on their daily life and functioning, which their current level of service provision is not addressing. The information provided will be looked at by a CAMHS Clinician in order to further consider what level of support or advice might be appropriate. Do not hesitate to follow established child protection procedures as soon as any requirement to do so is identified.

Please attach copies of any assessments, records or observations that will help us to assess the Mental Health needs of this child/young person.

Referral forms will be returned if there is insufficient information to assist our screening process.

1. Details of child or young person
First Name(s): / Surname:
Previous/AKA: / NHS Number:
Date of Birth: / Age: / Does this person have parental responsibility? / Yes: No:
If no, please state who does:
Lives with:
Address (including postcode):
Gender: / Female: Male: / Religion (if known):
Parent/Carer
Name: / Telephone No:
Mobile No:
Address:
(if different)
School/College/Nursery: / Year group:
Child Protection Register? / Yes: No: / Looked after child? / Yes: No:
Disability: (Please describe the nature of disability – including any support that may be needed by parent/carers in completing any forms sent) / SEN register:
School Action:
School Action Plus:
Statement:
Has there been, or is there any domestic abuse at home? / Yes: No: / Has there been, or is there currently SHEF/CAF involvement? / Yes: No:
If yes:
Current: Past:
GP: / Surgery:
Address: / Tel. No:
2. Ethnicity
White British  Caribbean  Indian  White & Black Caribbean  Chinese  White Irish 
African  Pakistani  White & Black African  Any other ethnic group  Bangladeshi 
Any other White background  Any other Black background  White & Asian  Not Given 
Any other Asian background  Any other mixed background 
If other, please specify: Immigration Status:
Child’s first language: Parent(s) first language:
Is an interpreter or signer required? Yes  No  Has this been arranged? Yes  No 
Details of any special requirements (for child and/or their parents):
3. Referrer details
Name: / Position:
Organisation/Agency:
Address:
Telephone No: / E-mail:
Have you seen this child/young person in connection with this service request? / Yes:
No: / Have you seen the parent/carer in connection with this service request? / Yes:
No:
4. Family and environmental factors
Please provide any relevant information related to family history, family composition (including siblings, other significant adults, etc), family functioning, well-being, wider family, housing, financial considerations, social elements.
5. Parents / carers
Please provide any relevant information related to basic care, emotional care, boundaries, stability, stimulation, modelling, own experiences of parenting, personal issues.

Torbay Child & Adolescent Mental Health Service

(CAMHS) Referral Form

6. Development of child or young person – main areas of concern
(please circle as appropriate where 1 = mild concern and 5 = extreme concern
General health / 1 / 2 / 3 / 4 / 5
Physical (including sensory) / 1 / 2 / 3 / 4 / 5
Cognitive / 1 / 2 / 3 / 4 / 5
Speech, language & communication / 1 / 2 / 3 / 4 / 5
Behaviour, emotional & social / 1 / 2 / 3 / 4 / 5
Participation in learning / 1 / 2 / 3 / 4 / 5
Progress & attainment in learning / 1 / 2 / 3 / 4 / 5
Self-care skills & independence / 1 / 2 / 3 / 4 / 5
Self-esteem / 1 / 2 / 3 / 4 / 5
Identity / 1 / 2 / 3 / 4 / 5
Peer relationships / 1 / 2 / 3 / 4 / 5
Please comment on any areas scored higher than 3:
7. Child or young person’s strengths / interests
8. Current Concerns
Please describe what is happening, where and when, how often and for how long, giving examples if possible and identifying any areas of risk. Please include any current medications or treatments. Also, is there anything else that may be influencing the current difficulties? What is the child/young person/family’s understanding of current difficulties?

Torbay Child & Adolescent Mental Health Service

(CAMHS) Referral Form

9. History
Please explain the background to current difficulties. Is it getting worse or staying the same? Has there been previous engagement with any services?
10. Actions already taken to support child/young person
Please give details of any support the child/young person or family have received from other services including specific strategies or interventions that have been tried and whether they have been successful.
11. What would you like to happen as a result of making this referral?
Please be specific about what the child/young person and family are wanting to address and how you think CAMHS could help
Tick all documents attached: Assessments  Reports  IEPs  Observations  Action Plans  PEPs  PSPs  Other  (please specify)

Signed …………………………………………………………………………………………………………(Referrer)

Print Name………………………………………………………………………….….Date …………………………….

Please return this form together with the completed agency list, signed parental/carer consent form and any additional attachments to:

Torbay CAMHS

The Annexe

187 Newton Road

Torquay

TQ2 7BA

Torbay Child & Adolescent Mental Health Service (CAMHS)

Please tick the services both currently and historically involved with this child/young person/family and provide specific names and contact details



AGENCY/

PROFESSIONAL/

ORGANISATION

CONTACT PERSON

CONTACT DETAILS

School nurse

Health Visitor
Counsellor
CAMHS
Paediatrician/Hospital Specialist Doctor
Educational Psychologist
Speech and Language Therapist
Physiotherapist
Occupational Therapist
Portage
John Parkes Unit
Young Carers
Social Care
Parenting Services
SureStart
Targeted Youth Support
YOT/Police
Checkpoint
Specialist Advisory Teacher / Consultant
Pegasus Centre
Outreach Services (please specify)
Attendance Improvement Officer
Other (please state)
Other (please state)

Torbay Child & Adolescent Mental Health Service (CAMHS)

PARENTAL / CARER CONSENT

Child/Young Person……….…………………..…… Date of Birth……..……....

School Attended ……………………………………….

In order for us to provide the best possible service, we may need to undertake assessments and contact other professionals working with you and your family to share relevant information.

Any information we are given will be kept confidential and will only be shared with other people where necessary. You will be kept informed of any progress and invited to take part in discussions as and when appropriate.

Please tick the appropriate boxes below to indicate your consent:

 I give permission for any necessary assessments on my child to be undertaken in their school / college / nursery and for my child to be seen by relevant professionals, which may include an educational psychologist.

I give permission for information to be shared with other agencies / professionals as necessary, which may include psychological services.

If you do not want us to contact or share information with a particular agency/professional, please advise the person referring your child.

The only exception to this is if there are concerns about a child’s safety, when we have a duty under the Children Act (2004) to pass on our concerns to the appropriate authority.

Signed…………………………………………………………… Parent / Carer

Print Name………………………………...... Date………………..……