Norfolk and Suffolk NHS Foundation Trust - CAMHS - 0-18 years old

“*” indicates required fields

Information about referred person

All the information requested on this form is required to ensure we provide a safe and responsive service. We are therefore unable to accept forms that are not fully completed. If you are a professional, to ensure that your patients access the correct service in a timely manner, please consult the CAMHS Referral criteria before completing this form.

For a medical emergency, dial 999.

For URGENT advice, signposting and access to crisis response please contact NHS 111 and select the mental health option.

Information About Referred Person

Name*

Title First Last

Date of Birth*

Day

Month

Year

NHS Number*

Ethnicity Optional Optional

Nationality Optional Optional

Religion Optional Optional

First Language Optional Optional

Interpreter Required*

Address*

Address Line 1 Address Line 2 Town/City County Postcode Country

Phone Optional Optional

(Home/Mobile): (If young person is over 13)

Permission to contact by SMS*

Permission to leave voicemail*

Other Phone Number Optional Optional

Enter Email Optional Optional Confirm Email Optional Optional

(If young person is over 13)
By giving us your email address, we are assuming that you consent to being contacted in this way.

Legal Status of Child/Young Person (In particular, who are the legal parents/guardians) Optional Optional

Is the young person a refugee or asylum seeker?*

Yes

Information about family members

Parent/Carer Name*

First Last

First Language Optional Optional

Interpreter Required*

Home/Mobile Phone Optional Optional

Other Phone Optional Optional

Do you consent to receiving text messages*

Yes

Enter Email Optional Optional Confirm Email Optional Optional

Who is the main point of contact for this referral?*

Parent/Carer/Guardian’s relationship to the young person?*

Is the young person adopted?*

Previous/Alternative Care Arrangements Optional Optional

Are any other family members currently being seen or have previously been seen by mental health services? If so, please give details Optional Optional

GP details

GP Name*

Practice Name*

Practice Address*

Address Line 1 Address Line 2 City Post Code

Phone Optional Optional

Email Optional Optional

School details

School Name Optional Optional

School Address

Address Line 1 Optional Optional Address Line 2 Optional Optional City Optional Optional Post Code Optional Optional

Phone Optional Optional

Email Optional Optional

Is extra support being received in education?*

What Level/Nature (if known) Optional Optional

EHCP Plan in place?*

EHCP Plan applied for?*

SENCO / Key Worker Name

First Optional Optional Last Optional Optional

SENCO / Key Worker Email

Enter Email Optional Optional Confirm Email Optional Optional

SEND considerations

Would a telephone triage be appropriate for this young person?*

If no, please explain why*

Does the Child /Young person / Parent/Carer require any reasonable adjustments?

Child*

Young Person*

Adult*

Please give details of specific reasonable adjustments that are required Optional Optional

Other agencies involved

Social Care Optional Optional

School Nursing Optional Optional

Speech Therapist Optional Optional

Occupational Therapist Optional Optional

Psychology and Therapeutic Services Optional Optional

Community Paediatrics Optional Optional

Youth Justice Optional Optional

Other Optional Optional

Safeguarding issues

Please provide brief details of current services parents are open to Optional Optional

If any member of the family is subject to a Children’s Safeguarding plan; is known to adult mental health services; is subject to any kind of legal restriction order/s or if you are aware of any relevant court cases either pending or current, please give details Optional Optional

Consent for referral

Has the Parent/Carer/Guardian or the young person (if aged 13 or above) given informed consent for this referral to be made?*

Does the young person agree to this referral being made?*

If no, please explain why this is the case*

It is important that the young person is aware of the referral and agrees that this referral is made as this will have a direct impact on their motivation to engage with our service. There are however certain circumstances where children / young people might not have capacity to consent to the referral.

Has the young person aged 13 or over given consent for our service to contact their parent/carer/guardian?*

We will contact the GP and any other referrer into our services, if the young person/carer does not wish the GP/other referrer to be contacted tick here

Do Not Contact Optional Optional

We will contact the School or College, if the young person/carer does not wish the school/college to be contacted tick here

Do Not Contact Optional Optional

If there are any safeguarding concerns this may be overridden.

Referred by

Name*

First Last

Job Title*

Organisation*

Team*

Mobile Phone Optional Optional

Other Phone Optional Optional

Email*

Address

Address Line 1 Optional Optional Address Line 2 Optional Optional City Optional Optional Postcode Optional Optional

Referrer

I am aware that there are delays between referral and assessment and agree to continue to provide oversight of the patient’s care and treatment where appropriate and consider this delay when planning care and support during this period. This will include creating a safety plan with the patient, family and their network.

Date of referral*

Day

Month

Year

I confirm I am aware*

I confirm

Reason for referral

Completion of the below questionnaire will greatly assist us in determining the young person’s needs and what service they require. Please draw on all the information you have available to you regarding the child/young person’s difficulties and tick as appropriate, however incomplete this may be. This Section can be completed by or in conjunction with parent/carer/young person and MUST accompany the referral. Please refer to CAMHS Referral Criteria.

None

Functioning = There may be transient difficulties and ‘everyday’ worries that occasionally get out of hand (e.g. mild anxiety associated with an important exam, occasional ‘blow-ups’ with siblings, parents or peers) but the child or young person is generally secure and functioning well in all areas (at home, at school, and with peers).
Distress of Young Person = No distress or noticeable difficulties in relation to this problem.

Mild

Functioning = Symptoms cause occasional disruption but do not undermine functioning and impact is only in a single context. All/most age-appropriate activities could be completed given the opportunity. The child or young person may have some meaningful interpersonal relationships.
Distress = Distress may be situational and/or occurs irregularly (less than once a week). Most people who do not know the child or young person well would not consider him/her/them to have problems but those who do know him/her/them well might express concern..

Moderate

Functioning = Functioning is impaired in at least one context but may be variable with sporadic difficulties or symptoms in several but not all domains.
Distress = Distress occurs on most days in a week. The problem would be apparent to those who encounter the child or young person in a relevant setting or time but not to those who see the child or young person in other settings.

Severe

Functioning = child or young person is completely unable to participate age- appropriately in daily activities in at least one domain and may even be unable to function in all domains (e.g., stays at home or in bed all day without taking part in social activities, needing constant supervision due to level of difficulties, no longer managing self-care).
Distress = Distress is extreme and constant on a daily basis It would be clear to anyone that there is a problem.

Not Known

This aspect of the case has not yet been adequately assessed by you to make a “none” rating. Do not use this rating when deciding between the other ratings (e.g., between mild and moderate) – just make your best guess between the best ratings.

Anxious/Worry*

Compelled to do or think things*

Panic*

Avoids specific things*

Repetitive problematic behaviours (Habit problems)*

Low mood*

Self-Harm (Self injury or self-harm)*

Suicidal Ideation*

Extremes of mood*

Behavioural difficulties*

Poses risk to others*

Carer/management of children and young people’s behaviour (e.g., management of a child/children)*

Doesn’t get to toilet in time (elimination problems)*

Disturbed by traumatic event*

Family relationship difficulties*

Problems in attachment to parent/carer*

Peer relationship difficulties*

Persistent difficulties managing relationships with others*

Does not speak*

Unexplained physical symptoms*

Self-care Issues (includes medical care management, obesity)*

Adjustment to health issues*

Please provide a brief narrative of the young person’s difficulties and impact on their daily functioning (at school, with friends, at home)*

Please describe the urgency of the referral and what planning you have done to keep the young person safe*

What is the current plan in attempting to resolve and/or manage the young person’s problems? What has been tried before, what has helped before and what has not? Ideas the family have about what they believe may help*

How long has the young person experienced these difficulties? Optional Optional

Please indicate if the young person has experienced any of the following events

Bereavement Optional Optional

Difficulties at school Optional Optional

Bullying Optional Optional

Parental separation Optional Optional

Parental conflict Optional Optional

Parental mental health issues Optional Optional

Difficult family dynamics Optional Optional

Physical Harm/Assaults Optional Optional

Accidents Optional Optional

Other current/past trauma Optional Optional

Please give further details (including when if known) Optional Optional

How does the young person/family view this referral? What in your view is the young person’s/family’s motivation and ability to engage? Optional Optional

Check your answers

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