CAMHS Professional Request for Help

If you are contacting CAMHS because you or a young person you know is in crisis, please call First Response on NHS 111 (select the mental health option) for 24/7 support.

Name of child/young person(Required)

Date of birth(Required)

Address

Street Address Address Line 2 City Post Code

Age

NHS number (if known)

Ethnicity

Telephone number – home (please say who it belongs to – parent/young person)

Telephone number – mobile (please say who it belongs to – parent/young person)

Request for involvement from:

Date of request for involvement

Education setting

Contact in education setting

Parent/carer name

Parent/carer contact number

Agencies involved and current support

If you answered other to the above, please specify

Presenting mental health concern and why you would like help from CAMHS. Please provide as much detail as possible.

Previous CAMHS involvement and outcomes:

How do you think CAMHS could support the child/young person? Please give as much detail as possible.

Are there any current/past child protection or risk issues such as:

Please provide details if you have ticked any of the boxes above

Consent to share information

Consent: This means you are agreeing to share personal information. We would like your consent to contact any agencies that are currently involved or who we consider may be of help. We may also want to contact other agencies that know you, such as your school, GP, Excellence Cluster or MDT Access to help us provide a better service to you. We will ensure that your personal information is kept confidential, unless there are specific concerns that require us to share your details, e.g. child protection concerns. You will be told of this.

Please tick if you are agreeing to use the CAMHS text reminder service. This will remind you of day and time of your appointment.

Yes

If yes please provide the mobile telephone number

Please indicate your preferred method of contact

SMS

Telephone

I agree information being shared between agencies to help me/my child:

Name of child/young person(Required)

Completion of this field will act as the signature of the young person

Name of principal parent/main carer(Required)

Completion of this field will act as the signature of the principal parent/main carer

Date