Referral Criteria for theNE and NC FCAMHS

Criteria: / Delete as applicable
The young person is under 18yrs old at the time of referral. / Yes/No
The young person has or is suspected of having a mental disorder (including neurodevelopmental disorder). / Yes/No
The young person is deemed to have high forensic needs and/or present high forensic risks. / Yes/No
The young person is deemed to require inputs by a specialist service in a multiagency context. / Yes/No
The young person presents high risk of harm to others and there is major family or professional concern. / Yes/No
The young person is in contact with the Youth Justice System. / Yes/No
The young person requires an appropriate secure setting. / Yes/No
The young person is currently residing in a secure setting. / Yes/No
Young Person Details
Name
Date of Birth
Address
Telephone Number
RiO/Paris Number
(if applicable)
NHS Number
Ethnicity
Status: (please tick all that apply)
Mental Health (Mental Health Act 1983 as amended) / Not applicable
Part 2 detentions
Part 3 detentions
Supervised community treatment
Other (please state)
Education / Education Health Care Plan (EHCP)
Social Care (Children Act 1989) / Not applicable
Section 20
Section 21
Section 25
Section 31
Section 38
Child in Need Plan
Child Protection Plan
Child in Care (LAC) Plan
Guardianship Order
Other (please state)
Criminal Justice / Not applicable
On bail
Recent Police contact
On Remand
Pre-Court Order
Sentenced to Custodial Order
Sentenced or Community Order
Other (please state)
Living arrangements at time of referral: (please mark relevant setting)
Home Setting / Birth family
Adoptive family
Other family
Welfare Setting / Foster care
Independent Living
Semi-independent Living
Residential Care
Residential School
Secure Care (welfare)
Criminal Justice Setting / Young offender Institution (YOI)
Secure Children Home (SCH)
STC
Mental Health Setting / Low Secure unit
Medium Secure unit
PICU
Open Adolescent unit
Other
Name of Parent/Carer/Person with Parental Responsibility
Address
(if different to YP’s)
Telephone Number
(if different to YP’s)
GP Details
Name, title, agency, and contact number of other professionals involved with YP
Referrer Details
Name
Profession/Designation
Agency
Address
Telephone Number
Email Address
Is this the lead/
co-ordinating professional / Yes/No (if No please give details)
Referral Details
Date of Referral
Specific Reason for Referral. Please give specific details of your anticipated outcomes
Current statement(s) of risk
Is there a current Risk Assessment?
(FACE, GRIST, Safe Summary etc) / Yes/No (delete as applicable)
Please attach the assessment
Background information
(please attach relevant documents and reports)
Prior input from CYPS / Yes/No (delete as applicable)
Details of input from CYPS-psychiatric and /or psychological history
Has young person and family/carer/ person with parental responsibility been informed and consented to the referral / Yes/No (delete as applicable)
FOR OFFICE USE ONLY
Date Referral Received / Consultation Date / Information Checked At Consultation / Amendments To Form

A service provided in partnership between

Northumberland, Tyne and Wear NHS Foundation Trust and

Tees, Esk and Wear Valleys NHS Foundation Trust