Online Referral Form

Fields marked * are required.
Fields marked ** are required when further information is needed to support the preceding question.

Consent

* Are you making this referral on behalf of yourself or someone else:

Myself Someone else

* Are you under 16?

Yes I am under the age of 16 No I am over the age of 16

* Do you consent to this request for support

Yes No

* I consent to the information in this form to be shared with other teams and agencies (eg, NHS services social, education etc) to enable me to get the best help.

Yes No

Please be aware that we may discuss this with you at a later date regarding sharing, dependant on the level of support you may require.
Without this consent it makes getting you the best help more difficult and may delay your progress/recovery.

* Does your parent/carer consent to this request for support?

Yes No

* If no please let us know why...

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If there is a reason you don't wish to discuss with your parents/guardians please call us on 0800 953 0222 (option 2)Monday-Friday 9-5.

* Does your parent/carer consent to the sharing of information with other NHS Services that may care for you?

Yes No

If there is a reason you don't wish to discuss with your parents/guardians please call us on 0800 953 0222 (option 2)Monday-Friday 9-5.

* Does your parent/carer consent to information being shared with other teams and agencies (e.g. Education services, Children’s Centres and social care) in order to identify the most appropriate support for you?

Yes No

If there is a reason you don't wish to discuss with your parents/guardians please call us on 0800 953 0222 (option 2)Monday-Friday 9-5.

Your comments regarding Consent if any

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We cannot accept any Requests for Support without consent from you. If you want to speak to someone about this please call 0800 953 0222

* I am:

Parent/Carer Professional

* How old is the young person in your care?

Under 16 years old Over 16 years old

* Do you consent to this request for support

Yes No

* Do you consent to the sharing of information with other NHS Services that care for your child/young person?

Yes No

Please be aware that we may discuss this with you at a later date regarding sharing of information, dependant on the level of support your child/young person may require.
Without this consent it makes getting your child/young person the best help more difficult and may delay their progress/recovery.

* Do you consent to information being shared with other teams and agencies (e.g. Education services, Children’s Centres and social care) in order to identify the most appropriate support for your child/young person?

Yes No

* Does your child/young person consent to this request for support?

Yes No

SET-CAMHS are only able to proceed with a referral for a child over 16 they have consented to the referral, unless diagnosed with a condition which does not enable them to do so.

* Is your child/Young person diagnosed with moderate/severe learning disability?

Yes No

* Does your child/young person consent to sharing of information with other NHS Services that care for them?

Yes No

Please be aware that we may discuss this with your child/young person at a later date regarding sharing of information, dependant on the level of support they may require.
Without this consent it makes getting your child/young person the best help more difficult and may delay their progress/recovery.

* Does the young person consent to information being shared with other teams or agencies (e.g. Education services, Children’s Centres and social care) in order to identify most appropriate support.

Yes No

Comments regarding Consent if any

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SET-CAMHS are only able to proceed with a referral for a child under 16 if parent/carer with parental responsibility has consented

SET-CAMHS are only able to proceed with a referral for a child over 16 they have consented to the referral, please discuss this referral with your child/young person before completing this referral

* How old is the child young person?

Under 16 years old Over 16 years old

* Do the parent/carer consent to this request for support for their child/young person?

Yes No

* Does the parent/carer consent to the sharing of information with other NHS Services that may care for their child/young person?

Yes No

* Does the parent/carer consent to information being shared with other teams and agencies (e.g. Education services, Children’s Centres and social care) in order to identify the most appropriate support for their child/young person?

Yes No

* Does the young person consent to this request for support?

Yes No

SET-CAMHS are only able to proceed with a referral for a child over 16 they have consented to the referral, unless diagnosed with a condition which does not enable them to do so.

* Is the Young person diagnosed with moderate/severe learning disability?

Yes No

* Does the young person consent to sharing of information with other NHS Services that care for them?

Yes No

* Does the young person consent to information being shared with other teams or agencies (e.g. Education services, Children’s Centres and social care) in order to identify most appropriate support.

Yes No

Comments regarding Consent if any

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SET-CAMHS are only able to proceed with a referral for a child under 16/Child with Learning Disability if parent/carer with parental responsibility has consented

SET-CAMHS are only able to proceed with a referral for a child over 16 they have consented to the referral, please discuss this referral with the young person before completing this referral

My Details

* What is your First Name

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* What is your Surname

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* What is your DOB

What is your NHS Number

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* What is your Address & Postcode

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* What is your Preferred Contact Number

Invalid contact number

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What is your Secondary Contact Number

Invalid contact number

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What is your Preferred Email Address

Your email will be added to the NHS record and you may be contacted by other NHS services

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Please confirm your Preferred Email Address again

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* What is your Preferred Method of Contact:

Enter Preferred Contact Method, more than one can be selected.

What is your GP Name

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What is your GP Address

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What is your GP Contact Number

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What is your School/College Name

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What is your School/College Address

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What is your School/College Contact Number

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What is your School/College Email Address

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What are your Pronouns?

Pronouns Continued

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What is your Language?

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Do you need an Interpreter?

Yes No Don't Know

What is your Religion?

What is your Ethnicity

What is your Nationality

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Child/Young Person Details

* What is your Young Person's First Name

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* What is your Young Person's Surname

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* What is your Young Person's DOB

What is your Young Person's NHS Number

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* What is your Young Person's Address & Postcode

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* What is your Young Person's Preferred Contact Number

Invalid contact number

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What is your Young Person's Secondary Contact Number

Invalid contact number

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What is your Young Person's Preferred Email Address

Your email will be added to the NHS record and you may be contacted by other NHS services

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* What is your Young Person's Preferred Method of Contact:

Enter Preferred Contact Method, more than one can be selected.

What is your Young Person's GP Name

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What is your Young Person's GP Address

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What is your Young Person's GP Contact Number

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What is your Young Person's Nursery/School/College Name

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What is your Young Person's Nursery/School/College Address

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What is your Young Person's Nursery/School/College Contact Number

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What is your Young Person's Nursery/School/College Email Address

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What is your Young Person's Pronouns

Pronouns Continued

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What is your Young Person's Language

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Does your Young Person require an Interpreter

Yes No Don't Know

What is your Young Person's Religion

What is your Young Person's Ethnicity

What is your Young Person's Nationality

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Child/Young Person Details

* Young Person's First Name

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* Young Person's Surname

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* Young Person's DOB

Young Person's NHS Number

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* Young Person's Address & Postcode

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* Preferred Contact Number

Invalid contact number

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Secondary Contact Number

Invalid contact number

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Young Person's Preferred Email Address

Your email will be added to the NHS record and you may be contacted by other NHS services

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* Young Person's Preferred Method of Contact

Enter Preferred Contact Method, more than one can be selected.

Young Person's GP Name

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Young Person's GP Address

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Young Person's GP Contact Number

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Young Person's Nursery/School/College Name

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Young Person's Nursery/School/College Address

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Young Person's Nursery/School/College Contact Number

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Young Person's Nursery/School/College Email Address

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Young Person's Pronouns

Pronouns

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Young Person's Language

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Interpreter Required

Yes No Don't Know

Young Person's Religion

Young Person's Ethnicity

Young Person's Nationality

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Referrer Details

* Referrer's Name

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* Job Title / Relationship to the young Person

Your Parent / Carer's Details

* What are your Parent / Carer's Names?

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What is their relationship to you?

Please describe their relationship to you

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What is their telephone number?

Invalid contact number

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What is their address?

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What is their email?

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Parent / Carer's Details

* Parent / Carer's Names

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* Your relationship to the young person

* Please describe your relationship to the young person

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* Your telephone contact

Invalid contact number

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Your secondary telephone contact

Invalid contact number

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* Your Address

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* Your Email

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* Please confirm Your Email again

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Referrer / Contact Details

* Agency if professional making the Request for Support

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* Telephone contacts

Invalid contact number

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Address

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* Email

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* Please confirm Email again

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* Parent / Carer's Names

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* Their relationship to the young person

* Please describe their relationship to the young person

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* Their telephone contact

Invalid contact number

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Their secondary telephone contact

Invalid contact number

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* Their Address

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* Their Email

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Your Other Agencies Involved

Do you know if you are on a Child Protection Plan?

Yes No

Do you know if you are considered a Child in Need?

Yes No

Do you know if you are a Looked After Child (LAC)?

Yes No

As you are under 16 and a LAC we also need your Social worker details for their consent.

What's the name of your Social Worker

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What's the email address of your social worker

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Have you been previously known to EWMHS or CAMHS?

Yes No

Do you know if you have an EHCP and if so when was it last reviewed?

Yes No

What is your last EHCP Date?

Are you currently having any counselling?

Yes No

Have you previously accessed any other services/counselling?

Yes No

Are you known to any Community Paediatric Services?

Yes No

Are you known to Hospital or Community Doctor?

Yes No

Are you known to Children With Disabilities Team?

Yes No

Are you known to the criminal justice system? Had any Police involvement? Courts? Or the Youth Offending Service?

Yes No

Are you known to SENCo?

Yes No

Are you known to Educational Psychology or Psychologist?

Yes No

Are you involved with the Educational Access department?

Yes No

Are you known to safeguarding?

Yes No

Are you known to School Nurse/Health Visitor?

Yes No

Are you known to Social Care or Family Solutions?

Yes No

Are you known to any other services you think would be useful to tell us about?

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Young Person's Other Agencies Involved

Is your young person on a Child Protection Plan?

Yes No

Is your young person considered a Child in Need?

Yes No

Is your Young person considered a Looked After Child (LAC)?

Yes No

As you are under 16 and a LAC we also need your Social worker details for their consent.

Name of your childs Social Worker

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Email address of your childs Social Worker

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Is your child previously known to EWMHS or CAMHS?

Yes No

Does your child/young person have an EHCP and if so when was it last reviewed?

Yes No

Last EHCP Date

Is your child/young person currently having counselling?

Yes No

Has your child/young person previously accessed any other services/counselling?

Yes No

Is your child/young person known to Community Paediatric Services?

Yes No

Is your child/young person known to Hospital or Community Doctor?

Yes No

Is your child/young person known to Children With Disabilities Team?

Yes No

Is your child/young person known to the criminal justice system? Police involvement? Courts? Or the Youth Offending Service?

Yes No

Is your child/young person known to SENCo?

Yes No

Is your child/young person known to Educational Psychology or Psychologist?

Yes No

Is your Educational Access department involved?

Yes No

Is your child/young person known to safeguarding?

Yes No

Is your child/young person known to Nursery Nurse?

Yes No

Is your child/young person known to School Nurse/Health Visitor

Yes No

Is your child/young person known to Social Care or Family Solutions?

Yes No

Any other services (please specify)

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Other Agencies Involved with Young Person

Is the young person on a Child Protection Plan?

Yes No

Is the young person considered a Child in Need?

Yes No

Is the Young person considered a Looked After Child (LAC)?

Yes No

As you are under 16 and a LAC we also need your Social worker details for their consent.

Name of Social Worker

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Email address of Social Worker

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Is the child previously known to EWMHS or CAMHS?

Yes No

Does the child/young person have an EHCP and if so when was it last reviewed?

Yes No

Last EHCP Date

Is the child/young person currently having counselling?

Yes No

Has the child/young person previously accessed any other services/counselling?

Yes No

Is the child/young person known to Community Paediatric Services?

Yes No

Is the child/young person known to Hospital or Community Doctor?

Yes No

Is the child/young person known to Children With Disabilities Team?

Yes No

Is the child/young person known to the criminal justice system? Police involvement? Courts? Or the Youth Offending Service?

Yes No

Is the child/young person known to SENCo?

Yes No

Is the child/young person known to Educational Psychology or Psychologist?

Yes No

Is the Educational Access department involved?

Yes No

Is the child/young person known to safeguarding?

Yes No

Is the child/young person known to Nursery Nurse?

Yes No

Is the child/young person known to School Nurse/Health Visitor

Yes No

Is the child/young person known to Social Care or Family Solutions?

Yes No

Any other services (please specify)

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What's happening for you?

* Description of your current situation

• Please describe what you have experienced?
• What may have led to your current concerns?
• What strategies or interventions have helped?
• Are there existing diagnoses (e.g. Dyslexia, medical diagnosis, Learning Disability, ASD, Autism, ADHD)?
• Highlight any risks you are aware of?

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What is the impact on your life at school

(E.g. attendance / learning / concentration) and on hobbies, activities, interests, and relationships with others.
• Are you attending school or home schooled?
• Do you have any extra help for learning? Is there a TAF (Team around the family meeting), One Plan or Education Health Care (EHC) Plan in place?
• Is a One Plan or TAF being considered or named on the SEN register?
• Please specify what your extra help consists of.

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What's your home situation like?

Please include what goes well at home and with your family.
Who lives at home?
A brief summary of your family life / family relationships
Please include any impact on your family life.
Please include the health of parents and siblings if this is causing you concern

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Description of current situation

* Description of your young person's current situation

(e.g. anxiety, low mood, emotional and behavioural difficulties, hearing voices, eating disorder, using drugs and alcohol, self-harm, suicidal ideation, harm to others etc)?
• Please describe what you have experienced or observed?
• What may have led to the current concerns?
• What strategies or interventions have helped?
• Are there existing diagnoses (e.g. Dyslexia, medical diagnosis, Learning Disability, ASD, Autism, ADHD)?
• Highlight any risks you are aware of?

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Outline impact on your young person's life at school

(E.g. attendance / learning / concentration) and on hobbies, activities, interests, and relationships with others.
• Is your young person attending school or home schooled? Please provide full details.
• Do they have extra help for learning? Is there a TAF (Team around the family meeting), One Plan or Education Health Care (EHC) Plan in place?
• Is a One Plan or TAF being considered or named on the SEN register?
• Please specify what the extra help consists of.

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What is your young person's home situation?

Please include what goes well at home and with your family.
Who lives at home?
A brief summary of family life / family relationships / parenting concerns.
Please include impact on family life.
Please include the health family members if this is felt to be significant.

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Description of current situation

* Description of current situation

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Outline impact on life at school

(E.g. attendance / learning / concentration) and on hobbies, activities, interests, and relationships with others.
• Is the child attending school or home schooled? Please provide full details.
• Is their extra help for learning? Is there a TAF (Team around the family meeting), One Plan or Education Health Care (EHC) Plan in place?
• Is a One Plan or TAF being considered or named on the SEN register?
• Please specify what the extra help consists of.

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Home situation?

Please include what goes well at home and with the family.
Who lives at home?
A brief summary of family life / family relationships / parenting.
Please include impact on family life.
Please include the health of parents and siblings if this is felt to be significant.

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Description of current situation

* Does your current concern relate to an Eating Disorder?

Yes No Not sure

Please include your height

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Please add your weight if you know it

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Has your GP given you a blood test or an ECG, please select which one?

Yes ECG Yes Blood Test No

Please tell us your concerns.

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Description of current situation

* Does your current concern relate to an Eating Disorder?

Describe changes you have noticed around eating / food (behaviour, mood, dietary and fluid intake) and activity levels.
Any concerns you have around weight loss and in regards to physical / medical state.
Discuss weight history including visual prompts (like loose fitting clothing) if you are not aware of weight figure or BMI

Yes No Not sure

Please include your young person's height

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Please add your young person's weight if you know it

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Do you know your young person's Body Mass Index?

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Has their GP taken a blood test or an ECG, please select which one?

Yes ECG Yes Blood Test No

Please explain your concerns.

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Description of current situation

* Does your current concern relate to an Eating Disorder?

Yes No Not sure

Height

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Weight if known

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Body Mass Index

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Has their GP taken a blood test or an ECG, please select which one?

Yes ECG Yes Blood Test No

Please explain your concerns.

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Description of current situation

* Does your current concern relate to a Learning Disability?

Yes No

Please note that for a referral to be accepted by the SET-CAMHS Learning Disability Team
We require a copy of the child/ young person’s EHCP and/ or their most up to date EHCP review, as our Team is commissioned to work only with children with a severe to profound learning disability - If completing an online referral, please submit this document with the childs details to the Referral email address

* What is your young person's level of Learning Disability?

Severe Profound

Please state any known diagnosis/ Syndrome

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* Does your young person have any physical / sensory disabilities e.g. do they use a wheelchair?

Yes No

Please provide us with some brief details

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Please describe the difficulties including information regarding the frequency, duration and severity of the problem.

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Description of interventions already undertaken. Please clarify by whom and indicate outcomes.

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Referrer’s view of the problem.

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The family’s view of the problem (if discussed)

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Description of current situation

* Does your current concern relate to a Learning Disability?

Yes No

* What is the young person's level of Learning Disability?

Severe Profound

Please state any known diagnosis/ Syndrome

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* Does the young person have any physical / sensory disabilities e.g. do they use a wheelchair?

Yes No

Please provide us with some brief details

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Please describe the difficulties including information regarding the frequency, duration and severity of the problem.

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Description of interventions already undertaken. Please clarify by whom and indicate outcomes.

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Referrer’s view of the problem.

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The family’s view of the problem (if discussed)

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Further information for this online referral form can be found here. This needs to be reviewed before making a referral.
If you would like to find out what happens to personal information held about you, please read our privacy policy for more information:
https://www.nelft.nhs.uk/download.cfm?ver=1014