hull and east riding camhs professional referral form · hull and east riding camhs professional...
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Hull and East Riding CAMHS Professional Referral Form
1. Child and Adolescent Mental Health Service professional referral form (CAMHS)
Please be aware that this referral form uses Third Party Service Providers, Vendors and Hosting Partners to provide the necessary hardware, software, networking, storage, and related technology required to support your referral. The IP address of the referrer will be recorded. All data entered is secure and hosted within the UK.
1. Priority of referral *
Emergency
Urgent
Routine
If this is an emergency referral please telephone the service directly on: - During office hours (9-5): through to contact point on East Riding referrals on 01482 303810 and Hull referrals on 01482 303688. - Out of office hours: through to the Crisis Team on 01482 335600
If there is an immediate threat to life call 999
Do not proceed with this referral, please contact the appropriate service as above.
About the young person
GP is from: *
Hull
East Riding
2. Name *
First name
*
Surname
*
Also known as
3. Date of birth * DD/MM/YYYY
Is the person is over 18 years old? *
Yes
No
If the person is over 18 years old, then DO NOT continue with this referral. Instead contact Adult services on: East Riding and Hull Single Point of Access: 01482 301701 select option 1. Out of hours: Hull: 01482 335710 East Riding: 01482 344564
4. NHS number - Full 10 numerical digits required
5. Male/Female
Male
Female
6. Ethnicity
White
British
Irish
Other Asian or Asian British
Indian
Pakistani
Bangladeshi
African
Any other Asian background Mixed
White and Black Caribbean
White and black African
White and Asian
Any other mixed background Black or Black British
Caribbean
African
Any other black background Other Ethnic Group
Chinese
Any other Ethnic Group
I do not wish to disclose my ethnic origin
Not known
7. First language
Interpreter required?
Yes
No
If so, which language?
8. Home address *
Street 1
*
Street 2
City
*
County
*
Post code
*
Telephone number (mandatory - must have at least one) * Landline or mobile
9. Parent/carer's name *
First name
*
Surname
*
10. Is the parent/carer's address the same as the young person's?
Yes
No
If no, please complete below Street 1
Street 2
City
County
Post code
Parent/carer's telephone number - landline or mobile
11. Relationship to young person
12. School/college
Name
Telephone number
13. GP name and address GP name
GP address
City
County
Post code
14. Have you seen the young person? *
Yes
No
If you are requesting an assessment then it is a requirement that you've seen this young person.
Do not continue any further with this form, your referral cannot be progressed without the appropriate permissions
Is the young person aware of this referral? *
Yes
No
Has the young person consented to this referral? If no, please give reason. *
Yes
No
Comments:
Does the parent/carer have the parental responsibility? If no, then who holds parental responsibility? *
Yes
No
Comments:
15. Has the person with parental responsibility consented to the referral? *
Yes
No
If 'NO' then is the young person deemed to be Gillick competent according to the Fraser guidelines? *
Yes
No
Consent is required from the person with parental responsibility before this referral can be continued.
About the referrer
16. Name of referrer *
First name
*
Surname
*
Job title
*
Agency
*
Phone number
*
Street 1
*
Street 2
City
*
County
*
Post code
*
Date of referral * DD/MM/YYYY
Other people/known agencies involved?
Has a formal assessment been undertaken? For example: CAF/Early Help/Core Assessment? COMMON ASSESSMENT FRAMEWORK: The CAF is a standardised approach to conducting a community based assessment of a child's global needs and deciding how those needs should be met. The CAF aims to ensure that everyone involved with the child or young person, – such as teachers and health visitors work
together at an earlier stage before their presenting needs increase further. *
Yes
No
Don't know
If 'yes' please attach details and name of lead professional
If needed, please attach relevant files
File: {{filename}}delete
Choose File
17. Past CAMHS involvement? If yes, please provide further information (mandatory) *
Yes
No
Don't know
Comments:
17. Referral pathways
These are the CAMHS referral pathways please select the main area of presenting difficulty.
18. Anxiety *
Yes
No
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
If has anxiety:
None Mild Moderate Severe Not known
Anxious away from care givers (separation anxiety)
Anxious in social situations (social anxiety/phobia)
Anxious generally (generalised anxiety)
Panics (panic disorder)
Avoids specific things (specific phobia)
Avoids going out (agoraphobia)
Unexplained physical symptoms. Adjustment to health issues
Does not speak (selective mutism)
19. Depression *
Yes
No
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
Depression/low mood
1 month
3 months
6 months
1 year +
Depression/low mood
Mild
Moderate
Severe
20. Self harm *
Yes
No
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
Self harm is
Mild
Moderate
Severe
Duration of self harm
1 month
3 months
6 months
1 year +
Medical attention required?
Yes
No
If yes, please give details:
21. Psychosis *
Yes
No
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
Pyschosis is
Mild
Moderate
Severe
25. Check list for psychosis
22. Please tick all that apply in the next four sections. Then add the four sections to give a total score. One point per tick:
The family is worried
Excessive use of alcohol
Use of street drugs (including cannabis)
Arguing with friends and family
Spending more time alone
Two points per tick:
Sleep difficulties
Poor appetite
Depressive mood
Poor concentration
Restless
Tension or nervousness
Less pleasure from things
Three points per tick:
Feeling people are watching you+
Feeling or hearing things that others are not+
Five points per tick:
Ideas of reference
Odd beliefs
Odd manner of thinking or speech
Inappropriate affect
Odd behaviour or appearance
First-degree family history of psychosis plus increased stress or deterioration in functioning
Total: If any + items are endorsed then consider referral to PSYPHER even if score is less than 20
23. Drugs and alcohol *
Yes
No
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
Drugs and alcohol usage are
Mild
Moderate
Severe
Type of substance (tick both if required)
Drugs
Alcohol
Type of drug used and frequency
24. Attention Deficit Hyperactivity Disorder (ADHD)/Attention Deficit Hyperactivity Disorder inattentive type (ADHD) *
Yes
No
Has a parenting programme been completed?
Yes
No
If yes, please give details
A parenting programme must be complete before a CAMHS referral will be accepted. Please contact EHASH on: (01482) 395500
Select one
ADHD
ADHD inattentive type
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
ADHD
Mild
Moderate
Severe
Duration of symptoms
1 month
3 months
6 months
1 year +
Presenting at home and school?
Home
School
Both
Conduct (referrals accepted for the age range 5-12 only) *
Yes
No
Has a parenting programme been completed?
Yes
No
If yes, please give details
A parenting programme must be complete before a CAMHS referral will be accepted. Please contact EHASH on: (01482) 395500
Select one
Conduct disorder
Oppositional defiant disorder
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
Conduct
None
Mild
Moderate
Severe
Not known
Duration of symptoms
1 month
3 months
6 months
1 year +
25. Eating disorder *
Yes
No
Disorder indicates
Anorexia nervosa
Bulimia nervosa
Eating disorder not otherwise specified (EDNOS)
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
Eating disorder
Mild
Moderate
Severe
Details:
Weight
Height
BMI
Base line pulse
Blood pressure
SCOFF Eating Disorder Questionnaire (patient to be asked the following questions):
Yes No
Do you ever make yourself sick because you feel uncomfortably full?
Do you worry you have lost control over how much you eat?
Yes No
Have you recently lost more than one stone in a three month period?
Do you believe yourself to be fat when others say you are too thin?
Would you say that food dominates your life?
26. Trauma *
Yes
No
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
Trauma
Mild
Moderate
Severe
Duration of symptoms
1 month
3 months
6 months
1 year +
When did trauma occur? Leave blank if not known DD/MM/YYYY
27. Gender discomfort *
Yes
No
Guidance on impact ratings None - No distress or noticeable difficulties in relation to this problem. Mild - Distress may be situational and/or occurs irregularly less than once a week. Most people who do not know the CYP well would not consider him/her to have problems but those who do know him/her well might express concern. Moderate - Distress occurs on most days in a week. The problem would be apparent to those who encounter the CYP in a relevant setting or time but not to those who see the CYP in other settings. Severe - Distress is extreme and constant on a daily basis. It would be clear to anyone that there is a problem.
Gender discomfort
Mild
Moderate
Severe
28. Relationship issues?
Yes
No
If yes, what issues?
Peer relationship difficulties
Family relationship difficulties
Persistent difficulties managing relationships with others
Details and duration
29. Why are you making this referral? *
Advice
Consultation
Assessment & treatment
Please give details
44. Risk and complexity factors
30. Suicidal thoughts? *
Yes
No
If yes, please comment on severity/frequency
Harm to self? *
Yes
No
If yes, please comment on severity/frequency
Harm to others? *
Yes
No
If yes, please comment on severity/frequency
Self neglect? *
Yes
No
If yes, please comment on severity/frequency
45. Selected complexity factors
31. Selected complexity factors *
Yes No Not known
Young carer status
Learning disability Serious physical health issues including chronic fatigue
Pervasive development disorders (Autism/Asperger's)
Neurological issues (tics or Tourette's)
Looked after child Current child protection plan
Deemed child in need of social services input
Refugee or asylum
Yes No Not known
seeker Experience of war, torture or trafficking
Experience of abuse or neglect
Parental health issues
Parental neglect Contact with Youth Justice System
Risk or exposure to Child Sexual Exploitation (CSE)
Risk or exposure to radicalisation
Risk of harm from others
Living in financial difficulty
Please provide any further important information you feel is relevant to the referral.
Click 'Finish Survey' to submit referral