MHST Referral Form

Children and Young People- Mental Health Support Team Service

Please note – this is a referral for our Mental Health in Schools Support Team and not a referral for CAMHS support. Our service supports children and young people aged 5 years- 18 years in Plymouth. We can only accept referrals for children and young people registered with a Plymouth GP. For urgent help with mental health needs, please contact NHS 111 and select the 'Mental Health option'. For adult mental health referrals, please contact Plymouth Options- 01752 435419 Consent: All children under the age of 12 need parental consent Self-referrals, age 12 + will be looked at by a case by case basis.

Are the parents/carers aware of this referral to Mental Health Support Teams?*

YES
NO

If 'no' please give a reason:

Is the young person aware of this referral to Mental Health Support Teams?*

YES
NO

If 'no' give a reason:

Does the young person/parent/carer agree to information being shared between school and/or agencies to help them receive help from the most appropriate source, including internal CAMHS services?*

YES
NO

Referral type

Name of referrer

Referrer's email address*

Position in school/organisation

What type of involvement are you requesting?*

One to one work with child
Parent/carer work
Timid to Tiger
Decider Group- Secondary
Psychoeducation/workshop in school
Staff training
consultation meeting with an EMHP
other e.g. advice and guidance, audit,

Child or young person's details

Title

Forename(s)

Surname

Preferred name

Date of birth

Age

Gender

Gender identified as

NHS Number (if known)

Address

Address Line 1 Address Line 2 Town or city County Postcode Country

Do you have a home telephone?

Yes
No

Home telephone number

Do you have a mobile telephone?

Yes
No

Mobile number

Child or young person's background

Ethnicity*

First language

Interpreter required?

Yes
No

Nationality

Sexual orientation

Religion

GP details

GP practice*

PLEASE NOTE: Currently we can only accept children & young people registered with a Plymouth GP

Practice address

Address Line 1 Address Line 2 Town or city County Postcode Country

GP telephone

Practice email address

School details

School

School address

Address Line 1 Address Line 2 Town or city County Postcode Country

School telephone

School email address

Parent/carer's details

Title

Forename(s)

Surname

Is the address the same as the child or young person's?

Yes, the address is the same
No, the address is different

Address

Address Line 1 Address Line 2 Town or city County Postcode Country

Do you have a home telephone?

Yes
No

Home telephone number

Do you have a mobile telephone?

Yes
No

Mobile number

Do you have an email address?

Yes
No

Email address*

Referral details

Please let us know why you are making this referral, including details of any previous or current mental health problems. The more information you include, the better we can decide on how best to help.

Please describe any mental health and emotional difficulties you might be having? Please include past and present. For example: mood, behaviour, sleep, concentration, motivation.

How is this impacting life in school and at home? Please add what measures school have put in place to support this.

How long have these been affecting you?

Has anything happened recently to make you seek help at this time?

Have there been any big family/life events or illnesses recently? If so please provide more information

Is there any further information that you think we should know?

Risk

Have there been any safeguarding concerns regarding this child or young person past or present? e.g Police, Social Care, Youth Justice. Please note: We cannot accept any referrals if the young person is at CIN level or above.*

Yes
No

If yes please provide details for above answer

Is the child or young person currently on an EHAT or TAM? *Please note we do not work with young people and families at CIN level or Child Protection**

Yes
No

Please provide details of the safeguarding concerns both past and present:

Are there any mental health risks in relation to this child or young person (e.g. risk of suicide/self-harm/risk from others)? *If there is a current concern of risk/suicide/suicidal thoughts please contact the First Response 24/7 Crisis line on 111 in the first instance*

Yes
No

Please provide details of the mental health risks:

Other organisations and support in place

Are you currently working with, or have you worked with, any other agencies, people or organisations, including your school? (e.g. Progeny, Young Devon, Strenghtening Families, MAST)

Yes
No

Please state the details of the Organisation/Agency/Individual and the work carried out:

Consent to leave a voicemail on the numbers provided?

Yes
No

Does the child/young person/parent/carer consent to the SMS text reminder service for appointments?

Yes
No

Untitled

Children and Young People- Mental Health Support Team Service

Child or young person's details

Child or young person's background

GP details

School details

Parent/carer's details

Referral details

Risk

Other organisations and support in place

01752 435502

Headquarters

Email