What is a CAMHS referral form?

A CAMHS referral form is a form you or the person who refers you to CAMHS will have to fill. The CAMHS referral form may differ from location to location but below is a sample of what a CAMHS referral form will contain and the sort of information you can expect to fill in.  

If you are referring someone to CAMHS you should look to fill this form with them in order to get the most up to date information. You should also check with the CAMHS location you are looking to attend on who they accept referrals from.

Remember, you should always seek content before referring anyone if you are not the parents, guardians or person being referred who is eligible to refer themselves.

What is CAMHS?

CAMHS is the NHS’s speciality division which helps children and young adults with mental health issues. CAMHS is a free service and you will have to be referred to CAMHS if you are under 16 except in certain situations where you may have the right to refer your self.

You can see a different CAMHS referral form from the Coventry CAMHS unit here and read more about the CAMHS referral process here.

Child and Adolescent Mental Health Service referral form (CAMHS)

Ealing CAMHS
1 Armstrong WaySouthallMiddlesexUB2 4SA

Tel: 020 8354 8160
E- mail referrals to:wlm-tr.EalingCamhs@nhs.net

Hammersmith & Fulham CAMHS
48 Glenthorne RoadHammersmithLondonW6 0LS

Tel: 020 8483 1979
E-mail referral to:wlm-tr.hfcamhs@nhs.net
Hounslow CAMHS
Heart of Hounslow Centre for Health92 Bath RoadHounslowTW3 3EL

Tel: 020 8483 2050
E-mail referrals to:hounslow.camhs@nhs.net

CAMHS Consultant helpline for Hounslow patients ONLY
020 8483 2452Every Tuesday 12 noon to 1pm
CAMHS Referral form for use from May 2018

Please email this completed form to your local CAMHS Service. Faxes will no longer be accepted from 1st July 2018.

We are required to register the full demographic details (including area of residency, GP details and NHS number) of all referrals. Please include this information in your referral otherwise we will need to return this form to you prior to triage.

Date of Referral
PRIORITY(see separate guidance)☐ Routine  ☐ Urgent☐ Emergency
Child/Young Person (Patient) DetailsParent/Carer/Guardian Details
First Name
Name of Mother
Surname
Address
NHS No
Home or Mobile Tel
DOB
Email
Gender
Name of Father
Ethnicity
Address
Address
Home or Mobile Tel
Area of Residency
Email
Home Tel
Name of Carer/ Guardian if applicable
Mobile Tel
Address if applicable
Email

Home or Mobile Tel if applicable
Email if applicable
Status☐Single  ☐Other ☐Not Specified
Main residence of child/young person
Main Language spoken
Main language spoken by family
Learning Disability☐No ☐YesLearning Disability☐No ☐Yes –
Physical Disability☐No ☐YesPhysical Disability☐No ☐Yes
Interpreter☐No ☐YesInterpreter☐No ☐Yes
GP Name if not referrer
Who holds parental responsibility?(give details e.g. parent/carer/Local Authority (LAC) include name and contact details if not already shown above)
GP Phone No
GP Address if not referrer
GP admin email address if known
School/Collegeif applicable
School/CollegeAddress
School/College Phone No
Special School☐No ☐Yes
Referrer Details
Name
Organisation code if applicable
Role/Title
Telephone No
Organisation
Email admin (NHS or egress)
Address


Consent – if this section is not completed fully, the referral will be returned to you prior to triage
Has the child/young person/family had previous involvement with this or any other CAMHS☐Yes
☐No
Do the parents/carer/guardians (who have parental responsibility) consent to this referral to CAMHS☐Yes
☐No
Do the parents/carer/guardians (who have parental responsibility) consent to this referral to CAMHS being shared with another more appropriate NHS or Local Authority Service? This includes being sent to another Trust such as CNWL.☐Yes
☐No
If no, are the parents/carer/guardians (who have parental responsibility) aware of this referral?☐Yes
☐No
If the young person is 16 years and over, does the young person consent to this referral to CAMHS☐Yes
☐NA
If the young person is 16 years and over, does the young person consent to this referral to CAMHS being shared with another more appropriate NHS or Local Authority Service? This includes being sent to another Trust such as CNWL.☐Yes
☐NA
If the young person is 16 years and over, does the young person consent to this referral being shared with their parents/carer/guardians?☐Yes
☐NA
Are there any other matters such as culture, language, illness, religion or disability that we may need to consider when getting in touch. If you have indicated that there is a learning or physical disability affecting the Child/Young Person or family member, please specify here:☐Yes
Give Details:
☐No
Reason for Referral
Reason for Referral
(Please specify why you think a CAMHS assessment is required and what you wish the service to do)

Main Concerns – Symptoms
(Give details about onset, duration, frequency, severity)

Settings (Home, School and Community)
(Neurodevelopmental disorders and other mental health conditions are pervasive across settings – home, school and community. Give details in relation to different settings)

Impact, Distress and Impairment
(Give details of child development, family life, social life, learning/academic performance)

Risk /Safeguarding Concerns


Is the family known to Children’s Social Services?☐No ☐Yes  ☐Unsure
If yes give details:
Does the child have an Education, Health & Care Plan (EHCP), Child Protection (CP) Plan, Child in Need (CIN) Plan?☐EHCP  ☐CP ☐CIN
Is the child/young person a Looked After Child (LAC)☐No ☐Yes  ☐Unsure
Is the child/young person/family currently involved in Legal Proceedings relating to the child/young person?☐No ☐Yes  ☐Unsure
If yes give details:
Are you aware of any domestic violence or abuse issues in this family?☐No ☐Yes  ☐Unsure
If yes give details:
Are you aware of any drug or alcohol issues in this family?☐No ☐Yes  ☐Unsure
If yes give details:
Medical History
(Give sufficient details to rule out organic conditions)

Current Acute Medication in last month
Current Repeat Medication

Allergies & Sensitivities
Interventions Previously Tried (Individual and/or family)
(Give details of school, universal/primary/secondary interventions)







Other Professionals Involved
Other Professionals Involved and Reports
(Give details of other agencies involved now or in the past with the child/young person and family)
Agency NameNamed WorkerAddressTel No
















Is the child/young person on a waiting list for a service?☐No ☐Yes  ☐Unsure
If yes give details:
Relevant reports attached☐No ☐Yes
If No, please give reasons as this may significantly delay the processing of this referral:
Please state which reports are attached

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