Referral Form

Step 1

Personal Information

Step 2

Living Arrangements

Step 3

Health and History

Step 4

History

Step 5

Contact Information

  • Step 1
  • Step 2
  • Step 3
  • Step 4
  • Step 5

Personal Information

Name

Date of Birth

Age

Address

Living Arrangements

Who does the child / young person live with and name?

Are they aware of this referral ?

Permission to Contact

If by Phone, who is it and the Number ?

Health

Doctors Surgery / Phone

Please state any health issues

Does the child/young person have any disability/access needs?

If Yes, please specify here

History

Has the child/young person ever been referred to CAMHS?

If yes, please give details

Are you aware of any child protection issues?

Is the child/young person known to social services?

Is the child/young person known to the police?

Is anybody in the family currently in or has been in any of the armed forces?

Is the child/young person a carer for any family member?

Contact Information

Name and contact details of the person making this referral

If referral is from an agency or other professional, name of agency or organisation and address

What has triggered this Referral (NB Information provided will be shared with client)?

Are there any issues relating to (please circle)

School/College Attended (if appropriate)

Preferred place for counselling, please circle