Self Referral Form2021-07-20T11:32:00+01:00

Self Referral Form

    Section 1: Who is being referred?

    What service would you like;

    Section 2: Who is making the referral?

    Same as above? If no, please provide details:


    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?:


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


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


    Section 6: Current General Practitioner Name and Address

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


    If Yes, is the referee a Looked After Child?


    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:

    Need a helping hand?
    Get in touch for support

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