CAMHS Referral (Professional)

UK Resident?*

Yes

No

Child's Age*

Children under the age of 7 are not suitable for video conferencing consultations

Child's Gender*

Male

Female

Contact Email Address*

Contact Telephone Number*

Parent / Guardian Name*

Parent / Guardian’s Contact Number*

Other professionals involved

Summary of primary mental health concerns, e.g. mood, sleep, appetite, obsessions, routines, anxiety, self-esteem, lack of interest in usual activities, poor self-care

Previous mental health input

CAMHS

Primary Mental Health

School Counselling

Drug/Alcohol Use

Medications prescribed by GP

Risk - please answer the following questions. Where evidence of risk is apparent details MUST be provided

Risk To Self

Risk to others e.g. aggressive behaviour, fire setting, property destruction?

Risk - Other

Please complete the form below