Section 1: Who is being referred?

Please enter your Date of Birth

What service would you like;

---Weekly Children SessionsFortnightly Children SessionsMonthly Children SessionsWeekly Adult SessionsFortnightly Adult SessionsMonthly Adult SessionsWeekly Family GroupFortnightly Family GroupMonthly Family GroupWeekly 70+ groupFortnightly 70+ groupMonthly 70+ group

Section 2: Who is making the referral?

Same as above? If no, please provide details:

YesNo

Section 3: Reason for Referral/Current Mental Health Concerns

Please provide details of the presenting problem (please consider the following):

Current concerns, family life/circumstances, daily functioning, appetite, sleep, self-harm, suicidal thoughts or any safeguarding issues, Social Services/Children Family Practice/Child Social Care/Adult Services involvement, any interventions you have currently tried or services you have been working or trying to work with, work, school or college attendance issues.

Section 4: Consent and Confidentiality of the Person Referred

Has the person given consent for the referral?:

YesNo

If the individual is under 16, has the person with parental responsibility been informed and given consent to the referral?:

YesNo

Section 5: Is there any history of parental mental health difficulties or substance misuse?

YesNoUnknown

Section 6: Current General Practitioner Name and Address

Section 7: Does the Referee have a Social, Child Family Practice, CAMHS, or any other Worker?

YesNo

If Yes, is the referee a Looked After Child?

YesNo

Section 8: Current School/College/University name and address (if referee is under 16)

Section 9: Background History of the Presenting Problem

Where do you think these issues have stemmed from? What makes them worse? What makes them better?
Do you have any other diagnosis: (physical health, neurodevelopmental, SEN, mental health)?

Section 10: Any other information that may be useful

How have you found us:

---Web searchRadioSocial MediaMy Organisation – Please name it in -Any other information-Attended a talk/trainingNATWEST HUBGP SurgeryWord of MouthDirect contact with AEMHSHarry Rainbow

I agree to the privacy policy