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? * 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 t known 7. First language Interpreter required? 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? 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? * 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? *
Has the young person consented to this referral? If no, please give reason. * Comments: Does the parent/carer have the parental responsibility? If no, then who holds parental responsibility? * Comments: 15. Has the person with parental responsibility consented to the referral? * If 'NO' then is the young person deemed to be Gillick competent according to the Fraser guidelines? * 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 * Email 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. * 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) * Don't know Comments: 17. Referral pathways These are the CAMHS referral pathways please select the main area of presenting difficulty. 18. Anxiety * Guidance on impact ratings ne - 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: 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) ne Mild Moderate Severe t known 19. Depression * Guidance on impact ratings ne - 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 * Guidance on impact ratings ne - 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? If yes, please give details:
21. Psychosis * Guidance on impact ratings ne - 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 * Guidance on impact ratings ne - 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) * Has a parenting programme been completed? 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 ne - 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) * Has a parenting programme been completed?
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 ne - 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 ne Mild Moderate Severe t known Duration of symptoms 1 month 3 months 6 months 1 year + 25. Eating disorder *
Disorder indicates Anorexia nervosa Bulimia nervosa Eating disorder not otherwise specified (EDNOS) Guidance on impact ratings ne - 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): Do you ever make yourself sick because you feel uncomfortably full? Do you worry you have lost control over how much you eat?
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 * Guidance on impact ratings ne - 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 *
Guidance on impact ratings ne - 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? 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? * If yes, please comment on severity/frequency Harm to self? * If yes, please comment on severity/frequency Harm to others? *
If yes, please comment on severity/frequency Self neglect? * If yes, please comment on severity/frequency 45. Selected complexity factors 31. Selected complexity factors * Young carer status t known 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
seeker Experience of war, torture or trafficking Experience of abuse or neglect Parental health issues t known 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