North Cumbria Specialist Child and Adolescent Mental Health Services (SPECIALIST CAMHS) Referral Form 
INCOMPLETE FORMS AND UNJUSTIFIABLE REQUESTS WILL BE RETURNED TO THE REFERRER

PLEASE NOTE IF THE CHILD/YOUNG PERSON IS NOT SEEN AS PART OF THE REFERRAL, IT WILL NOT BE ACCEPTED

IF THERE ARE IMMEDIATE SAFEGUARDING CONCERNS THEN IT IS THE RESPONSIBILITY OF THE REFERRER TO CONTACT THE SAFEGUARDING HUB.

This referral form is for access to services providing mental health interventions across North Cumbria. Your referral may be reviewed by representatives from each organisation. Onward referral to other agencies will be completed on your behalf where clear consent is included on this form. 	

PATIENT DETAILS: 	                               Referral Date:     	
SURNAME: 
	DOB:  
	GP PRACTICE:

Practice code:   
Registered GP: 	
FIRST NAME: 
      	AGE:
		
NHS NUMBER:	GENDER: 		
ETHNICITY:	PREFERRED PRONOUNS: 		
RELIGION:  		
ADDRESS: 

		
IS IT SAFE TO CONTACT: 		
PHONE NUMBER (INCLUDE IF PARENT/CARER’S):
Home: 
Mobile: 
Email:  	INTERPRETER REQUIRED? 
(if yes, state language including signing)    
YES  NO  	
NAME OF PERSON WITH PARENTAL RESPONSIBILITY: 

RELATIONSHIP TO REFFERRED CHILD:

Any special circumstances e.g. Foster Carer, Special Guardianship: 

ADDRESS:

PHONE:
EMAIL:	Consent to send letters by Text – Young Person
YES  NO 
Phone number:
Consent date:

Consent to send letters by Text – Parent Carer.
YES  NO 
Name: 
Phone Number:
Consent Date: 	
SCHOOL: 

Main contact at school: 	Is school attendance an issue? 	              
                    DON’T KNOW        YES     NO 	
DISABILITY (if yes, provide details): 								YES     NO 
	
Neurodiversity (diagnosed or suspected): 	
Children’s Safeguarding	
Is the child/young person “looked after” as defined in the Children’s Act 1989?			YES     NO 	
Is the child/young person adopted?								YES     NO 	
Are there safeguarding concerns about the child/young person or family? (if yes, provide details)	YES     NO 

	
Does the child/young person have a Child in Need Plan (CIN)                               DON’T KNOW          YES     NO 	
Is the child/young person subject to a Child Protection Plan?		   DON’T KNOW          YES     NO 	

Does the Young Person require support for the emotional impact of a trauma: 
Please provide additional details including approximate dates. If there are concerns the young person is not currently safe, please refer to Children’s Social Care. 

Domestic Abuse      YES     NO Details: 
Sexual Abuse           YES     NO Details:
Physical Abuse        YES     NO Details:
Emotional Abuse    YES     NO Details:
Other (please specify): 
	
Please detail if the perpetrator has been convicted or if there are ongoing investigations with police:
	
Please detail approximate time lapsed since the trauma:	

OTHER SERVICES / PROFESSIONALS INVOLVED (also include services they have been referred to):
Please be aware we may contact the organisations involved in their care.	
Name	Agency, and what support they are providing.	Contact Tel No 	

			
			
Has an Early Help/ Family Help Assessment been completed?	                 DON’T KNOW          YES     NO 
FURTHER HELPFUL INFORMATION: e.g. early help referral done by school:
	
What help has been sought prior to this referral (if not already detailed above): 

	
Does the parent or carer have any known literacy problems? (if yes, provide details)			YES     NO 
	
Do the parents/guardians have parental responsibility?						YES     NO 	
Are the parents/guardians agreeable to the referral?						YES     NO 	
Is the child/young person aware of the referral?							YES     NO 	
Has the child/young person requested this support?						YES     NO 	

REFERRAL DETAILS:		
Reason for the referral:

•	What are the current difficulties?
•	Duration of current difficulties?
•	Impact on functioning?
•	What are the young person’s strengths? 
•	What support is being requested for this young person? 

	
What has the young person or family experienced that may be relevant to understanding the current difficulties? 

		

SIGNIFICANT MEDICAL HISTORY
Active
Date	Problem	Associated Text	Date Ended	

Significant Past
Date	Problem	Associated Text	Date Ended	

 
MEDICATION
Acute
Drug	Dosage	Quantity	Last Issued On	

Repeat
Drug	Dosage	Quantity	Last Issued On	

Is the Young person on Hormonal Contraception?	Type	*If yes please specify whether mental health symptoms occurred before or after starting hormonal contraception?	*Note, although research is inconclusive, there is some evidence to suggest that hormonal contraception may impact mood. We would advise that this is considered prior to making a referral.	
Yes/no				

ALLERGIES: 

ALCOHOL, NICOTINE, OR SUBSTANCE USE (please detail): 

RISK ASSESSMENT:	
Are there any issues that place this young person or others at risk?		                                YES     NO 
(if yes, provide details including dates of incidents, nature of harm, frequency of incidents, triggers)

	
Can this person be worked with on a one-to-one basis? (e.g. absconding, damage to property, risk to professionals)                            	                                                                                                                                                                         YES     NO 	

AGREEMENT TO REFERRAL:	
The information on this form will be used to assess the emotional and mental health needs of the referred child/young person. Sometimes we may be able to re-direct the referral to a more appropriate service if consent is obtained to share the information with other agencies.

Have the parents/guardians given consent to allow CAMHS to share information as specified above?	YES     NO 
	
Have the parents/guardians given consent to allow CAMHS to contact the referrer and other involved agencies to discuss this referral further?                                                                                                                        	YES     NO 

REFERRER DETAILS:	
REFERRER’S NAME: 

REFERRER’S JOB TITLE OR RELATIONSHIP TO THE YOUNG PERSON:

REFERRER’S ORGANISATION AND ADDRESS: 

TEL: 

EMAIL:	
SIGNATURE:	DATE: 	

CEDS Referral Form Triage Prompt Questions

Does the young person present with a suspected eating disorder?
Do they appear to have body image distortion? Are they deliberately attempting to lose weight in an unhelpful way, particularly if weight loss is not clinically indicated? Include an eating disorder diagnosis if this has been given. 	

	
What is the young person’s current weight and height? And do they have a history of weight loss? If so, please give details including the current rate of weight loss. 	

	
Is the young person currently restricting their food or fluid intake? If yes, please give details. If malnutrition or dehydration is suspected, please include details of any physical health symptoms	

	
Does the young person report binging (eating large volumes of food in a short space of time) episodes? If yes, please give details. 	

	
Does the young person report any compensatory behaviours to control or reduce their weight – these include vomiting, laxatives, excessive exercise, diet pills? If yes, please give details. 	

	
For any suspected eating disorder, an assessment of physical health risk is essential. Please consider when the young person last saw their GP and consider requesting an urgent appointment to check the following according to Junior MARSIPAN Guidelines: blood biochemistry (full FBC’s, U’s and E’s, Potassium, Magnesium, Phosphate, LFT’s), blood pressure standing and sitting, temperature, pulse rate, weight and height and attaching these results to the referral. Seeks guidance from CEDS clinicians if you are unsure. 	

SEND REQUEST TO:	Tel Number	Email	
West Cumbria: 	
Park Lane Clinic, Park Lane, Workington, Cumbria CA14 2RR	
01228 603019

CMB-ChildrensReferralHub@cntw.nhs.uk
	
East Cumbria	Fairfield Centre, Carleton Clinic, Cumwhinton Drive, Carlisle, Cumbria CA1 3SX
	
01228 603019
	CMB-ChildrensReferralHub@cntw.nhs.uk