Cambridgeshire Community CAMHS

Single Point of Access, MARU, Chord Park, Godmanchester, Cambs., PE29 2BQ

T: 01480 428115 F: 01480 428149 E: accesscamhs@nhs.net Opening Hours: Monday to Friday 9a.m. to 5p.m.

CAMBRIDGESHIRE COMMUNITY CAMHS REFERRAL FORM

All formal referrals should be made using this referral form. The majority of children and young people who require our services will already have a co-ordinated support plan in place and referrals should be supported with the CAF documentation wherever possible.

For very urgent or emergency referrals during working hours, we will accept a telephone referral, followed by a referral form and supporting information. Out of hours: If a child or young person presents with an urgent physical or medical concern and you think they are at risk, they should be taken to the local A&E Dept. who will, if necessary, contact the on-call clinician.

Name of child/young person for whom the service is being requested:

Name, address and contact details of professional generating the referral:
Name:
Job title:
Agency:
Address:
Email address:
Telephone (office/base):	Telephone (home):
Signature:
Date of request:

To be completed by CAMHS staff:
Person screening case:
Decision made:	Date:
Comments:

SECTION 1A) Child/young person’s details:
First name:	Last name:
Also known as:	Date of birth:
Gender:
Age:
Ethnicity:
Current educational contact name and address	Telephone/contact details
NHS no.:
Current general practitioner name and address

(if not referrer)
Home address

(including postcode):
Home telephone no.:	Mobile:
Is the child/young person aware of the referral?
Does the child/young person consent to this referral being made?
Has the child/young person been given information about CAMHS?

SECTION 1B) Living arrangements and key relationships:
Child/young person is:
If “Other”, please state:
Child has siblings:
Siblings living at home?
Details of parent(s)/main carers/siblings:
Name	Relationship	Contact details	Parental responsibility

SECTION 2 Needs and concerns
2A) Reasons for referral:

Please state nature of difficulties, onset, frequency and duration, interventions tried; impact on child and family; impact on education; and any relevant medical history

2B) Social/family background:

Please provide details of family composition and ages, occupations/employment, any parental mental health concerns, any child welfare concerns and relevant life events e.g. divorce, separation, bereavements, domestic violence, drug/alcohol misuse

2C) Impact on child/young person at school:

Please provide information on the child’s behaviour and attainment/performance at school.

2D) Child/young person:

Please give details of what the child/young person would like to happen as a result of this referral.

2E) Parents/carers:

Please give details of what the parent(s)/carers want to happen as a result of this referral.

SECTION 3 Outcome anticipated:

In making this referral, what outcomes are you anticipating for the child/young person/family?

SECTION 4 Other agencies involved
4A) Please tick if any of the following professionals/services have worked with the child/young person/family
Nursery/pre-school	Other CAMHS service
Health visitor	School nurse
Locality team	Paediatrician
MST	Educational psychologist
Youth offending team	Education welfare officer
Inclusion learning support	Adult mental health services

(for parent(s)/carers)
Not applicable	Others, please state:

4B) For each agency currently working the child/young person/family, please provide the following details:
Agency	Name/role	Start date	Contact details

SECTION 5 CONSENT

Please note this section is important and MUST be completed.
Do you have the parent/carer’s consent for this referral?
Does the parent/carer give consent for contact with other agencies (as shown in Section 4) who are involved with the child/young person/family and the sharing of information?

Or only with the following agencies/professionals:

Does the young person give consent for contact with other agencies (as shown in Section 4) who are involved with the child/young person/family and the sharing of information?

Or only with the following agencies/professionals:

Has this form been copied to the parent/carer?
Has this form been copied to the child/young person?
If the child/young person was seen alone, are their parent(s)/carer(s) aware of the referral?

5B) If no consent is given please state why:

Any other comments:

Send referral form (and CAF wherever possible) to: accesscamhs@nhs.net (preferred) F: 01480 428149

For urgent/emergency referrals during working hours / advice / consultation: T: 01480 428115

Aparna Konduru

2016-11-16

Harris Claire E

ASP