Hampshire CAMHS Non GP Referral

Young Person Details

Forename*

Surname*

Also known as

Date of Birth*

NHS Number*

Gender*

Sexual Orientation*

Address at which the child/young person is currently living

Address Line 1*

Address Line 2

City*

County*

Postcode*

Landline/Home Telephone Number*

Child/Young Person Mobile Number If appropriate.

In the interests of the environment and costs to the service, we would like to email correspondence and appropriate documentation to you. Do you consent to us using your email address for these purposes?

I consent?*

Yes

No

Please select the most relevant option: *

I am the person being referred (Self-referral)

I am the parent/guardian of the person being referred

I am a professional completing a referral on behalf of the young person/parent/guardian

Is the child/young person (please select all that apply)*

Living with parent/s

Living with relative/s

Living with Other i.e. friend/s

Looked After Child

Subject to a Child Protection Plan

Child in need

Adopted

Children In Care Details

(to be completed by social worker where relevant)

Originating local authority (Authority when child was originally placed in Hampshire)

Current legal status of young person

Please provide details of who holds parental responsibility

Who can provide consent (such as to share information with other agencies)

If a foster carer: Does the foster career have delegated authority to accompany a young person to CAMHS appointment?

Yes

No

Current Placement Details

Time in current placement

Is this a long term careplan?

Yes

No

Have there been any previous placements?

Yes

No

Biological family contact details

Relevant child/young person interaction with biological family details to consider (E.g. court ordered)

Please provide detail of relevant history leading to child/young person being placed in care, E.g. exposure to adverse childhood experience

Please provide detailed chronology and timeline, genogram and any relevant reports

Young Person Details Continued

First language*

Does the child/young person have a disability?*

Yes

No

Is the child/young person a Young Carer?*

Yes

No

Will any changes be required in order for the child/young person to access CAMHS (such as communication or environment)*

Does the child/ young person or the parent/ carer require an interpreter?*

Yes

No

Name of GP*

GP surgery name*

GP surgery telephone number

GP surgery email address

GP surgery address*

Ethnicity:*

Religion*

Other Service's Contact Details

Are there any other services or contacts that we should know about?*

Yes

No

Does the young person have a Youth Justice Worker allocated?*

Yes

No

Referrer Details

Name*

Job title/profession

Address*

Postcode*

Telephone number*

Email address*

Date of referral*

Terms and Conditions

On receipt of the referral we will consider whether or not a specialist mental health service may be the most appropriate service. If an appointment is offered this will be prioritised based on the presenting need. There are a number of things that can be done whilst the family wait for an appointment. Please click here for more information. If you are concerned about a deterioration in presentation please call one of our SPA teams on 02382 317 912 option 1 between 9am and 12pm. You may also email us on HIOWH.CAMHSSPA-Hants@nhs.net. Please support the family in accessing this support and let us know if there is a deterioration in the young person's presentation.

The information you have provided will only be used for the purpose of receiving your referral and contacting you for further information about your referral. Your information will not be shared with anyone else without your consent. Information will be held as a part of the service user's record in line with the NHS Records Management Code of Practice. For more information on how we use your information, please see our privacy policy.

I have read and agree with the above terms and condtions and agree with this website's privacy policy.

Hampshire CAMHS Referral Form

Hampshire CAMHS Referral Form

Young Person Details

Referral Consent

Mental Health Needs and Concerns

Young Person Details

Children's Services Information

Children In Care Details

Current Placement Details

Young Person Details Continued

Parent/Carer Details

Other Service's Contact Details

Education/Not in Education (NEET)

Referrer Details

Terms and Conditions