Cambridgeshire and Peterborough Community CAMHS
Single Point of Access, MASH, Chord Park, Godmanchester, Cambs., PE29 2BQ
T: 01480 428115 F: 01480 428149 E: [email protected]
CAMBRIDGESHIRE AND PETERBOROUGH COMMUNITY CAMHS
SINGLE POINT OF ACCESS REFERRAL FORM
All formal referrals must be made using this referral form. The majority of children and young people
who require our services will already have a co-ordinated support plan in place and referrals should be
supported with the CAF documentation wherever possible.
For very urgent or emergency referrals during working hours, we will accept a telephone referral,
followed by a formal referral and supporting information. For emergencies out of hours, contact the
local A&E Dept., who will, if necessary contact the CAMHS on-call clinician.
Name of child/young person for whom the service is being requested:
NB: Any child/young person for whom a service is requested must have been assessed in person prior to requesting our
involvement.
Name, address and contact details of professional generating the referral:
Name: ______________________________________________________________________
Job title: ____________________________________________________________________
Agency: ____________________________________________________________________
Address: ____________________________________________________________________
Telephone: Office/Base: _____________________ Mobile: ____________________________
Signature: ___________________________________________________________________
Date of request: ______________________________________________________________
Section 1 a) Child/young person’s details:
First name: __________________________
Last name: ___________________________
Also known as: ______________________
Date of birth: ________________________
NHS no. ___________________________
Current educational contact name and address:
_____________________________________
Telephone or contact details ______________
_____________________________________
Current General Practitioner name and address
Age ______Male
Female
(if not referrer):
Ethnicity: _________________________
_____________________________________
Home address (including postcode): ____ ___________________________________________
___________________________________________________________________________
Home telephone no. : _______________
Mobile: ___________________________
Is the child/young person aware of the referral?
Yes
No
Does the child/young person consent to this referral being made?
Yes
No
Has the child/young person been given information about CAMHS? Yes
No
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Section 1 b) Living arrangements & key relationships:
Child/young person is:
Living with parent/s
Looked after
Kinship placement
Other, please state ___________________________________
Child has siblings? Yes
No
Adopted
Siblings living at home? Yes
No
Details of parent(s)/main carers/siblings:
Name
Relationship
Contact details
Parental Responsibility
Yes
No
Yes
No
Section 2 Needs and concerns
2 a) Reasons for referral:
Please state nature of difficulties, onset, frequency and duration, interventions tried; impact on child and family; impact on
education; and any relevant medical history.
2 b) Social/family background:
Please provide details of family composition and ages, occupations/employment, any parental mental health concerns, any
child welfare concerns and relevant life events e.g. divorce, separation, bereavements, domestic violence, drug/alcohol misuse.
2 c) Impact on child/young person at school:
Please provide information on the child’s behaviour and attainment/performance at school.
2 d) Child/young person:
Please give details of what the child/young person would like to happen as a result of this referral.
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2 e) Parents/carers:
Please give details of what the parent(s)/carers want to happen as a result of this referral.
Section 3: Outcome anticipated
In making this referral, what outcomes are you anticipating for the child/young person/family?
Section 4: Other agencies involved
4 a) Please tick if any of the following professionals/services have worked with the
child/young person/family
Nursery/Pre-school
Other CAMHS service
Health Visitor
School Nurse
Locality Team
Paediatrician
MST
Educational Psychologist
Youth Offending Team
Education Welfare Officer
Inclusion Learning Support
Not applicable
Adult Mental Health services
(for parent(s)/carers)
Other, please state _________________________
_________________________________________
4 b) For each agency currently working the child/young person/family, please provide
the following details:
Agency
Name and role
Start date
Contact details
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Section 5: Consent.
Please note this section is important and MUST be completed.
1. Do you have parental/carer/child/young person’s consent for this referral?
Yes
No
2. Do the parent(s)/carers give consent for contact with other agencies involved with the
child/young person/family as shown in Section 4 and sharing information?
Yes
No
or only with the following agencies/professionals:
______________________________________
3. Has this form been copied to the parent(s)/carers?
Yes
No
4. If the child/young person was seen alone, are their parent(s)/carers aware of the referral?
Yes
No
5 b) If no consent is given please state why:
Any other comments:
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