Required

Section 1: Child / Young Person and Family name, address and contact details

Required
Title Required
Required
Required
Required
Required
Required
Required
Required
Translator / interpreter required? (including sign language) Required

Section 2: Reason for Referral / Current Mental Health Concerns

Please provide brief detail of presenting problem in the box below (please consider the following);

Presenting concern, family life/ circumstances, daily functioning, appetite, sleep, self-harm, suicidal ideations any safeguarding Issues, Social Services involvement, any intervention that have been tried, any school/college attendance issues

Required

Section 3: Referrers name, address and contact details

Required
Required
Required
Required
Required

Section 4: Consent and confidentiality of the person referred

Has the person given consent to the referral? Required
If the individual is under 16 has the person with parental responsibility been informed and given consent to the referral? Required
Required
Required
Required

Section 5

Is there any history of parental mental health difficulties or substance misuse?

Section 6: Current General Practitioner name and address (if not referrer)

Section 7

Does the child / young person have a social worker?
If yes, is the child / young person a Looked After Child?

Section 8: Current Education name and address: (we will not contact school unless parent/patient consent has been given)

Section 9: Background History

Section 10: Risk Assessment

History of risk? Required
Current risk? Required
Level of risk? Required
Is there drug and alcohol misuse? Required
Have they been referred to drug and alcohol services? Required
Is there an agreed safety plan? Required

Section 11