Required

Consent

  • The young person should be informed that they are being referred to FCAMHS. 
  • The only exception to this will be if the referring professional believes informing the young person will increase risks to the young person and/or others.
Have you discussed the referral with the young person? Required
Has the young person agreed/consented to the referral? Required
Has consent been obtained from parent/carer/person with parental responsibility? Required

The referrer must decide if there are sufficient grounds for safeguarding reasons to submit a referral without the required consent. Without the young person’s consent, FCAMHS will be unable to provide direct assessment/intervention even if it is indicated.

  • By submitting this referral, you confirm that you have followed your local consent policies. This includes gaining the relevant consent for referring to FCAMHS, and the sharing of appropriate information across agencies involved.
  • FCAMHS (North East and North Cumbria) is a service provided by CNTW and TEWV and therefore relevant information may be shared between the two organisations.
     

Young Person’s Information

If the young person is known to CNTW or TEWV please complete Paris or RIO ID. 

Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required

Referrer Information

  • The referrer must be a care coordinator/lead professional who will retain overall responsibility for the case and remain involved until the conclusion of any FCAMHS (North East and North Cumbria) involvement.
  • As referrer you agree to take full responsibility for ensuring all relevant professionals’ details and information are provided to FCAMHS.
Required
Required
Required
Required
Required
Required
  • Please ensure you have discussed this referral and submission with your manager/supervisor.
  • Please enter the details of this individual below.
Required
Required
Required
Required

Agencies Involved

CAMHS/CYPS contact (not FCAMHS)

If this referral is being made by CNTW CYPS/TEWV CAMHS, please ensure that the CPA reflects enhanced care coordination and care plans/risk assessments are up-to-date. 

Required
Required
Required

CAMHS professionals involved

Current Living Arrangements
Social Care Status Required

Social Care professionals involved

Education status

Education type Required
Address
EHCP
If YES, please give date of last plan
Invalid date
Does the young person have any communication barriers?
If YES, date report was completed
Invalid date

Criminal Justice Status

Select:

Criminal Justice professionals involved (YOT, Probation, etc.)

Address
Has referral been discussed?
Address
Has referral been discussed?

Other professionals involved (Substance Misuse worker, CSE worker, support worker, CJLD, etc.)

Address
Has referral been discussed?
Address
Has referral been discussed?
Address
Has referral been discussed?
Address
Has referral been discussed?
Address
Has referral been discussed?

SECTION E: Identified Risks

Select:
Has a risk assessment been completed?
Has this young person been discussed within your internal service/agency risk management processes?

SECTION F: Reasons for referral to a specialist forensic mental health service

High risk of high harm to others behaviour:

  • Please provide details of high risk of high harm to others/forensic behaviours including specific incidents of concern.
  • Include dates of incidents within the last 12 months. 
  • Please attach a separate chronology of incidents for behaviours prior to this.
Required