Email* completed referrals to Consultation line - 0300 304 0050 *Disclaimer: Please be aware that sending by email from iCloud, Gmail, Hotmail, Live, Yahoo or other private email accounts to NHS.net is not secure. If you would prefer to send the referral form via post please send it to the relevant postal address given in Section 8 ‘Referrals Criteria’ Hampshire Specialist Referral (please refer to Section 8 for referral criteria) Name of CAMHS Clinician, if referral is taken over the phone: SECTION ONE – YOUNG PERSON DETAILS Forename Surname Also known as Date of Birth Gender NHS No. Address at which the child/young person is currently living Landline / home telephone number person mobile number Parent’s/Carer’s mobile number Is the Child / Young Person: (tick all that apply) – □ Living with parents □ Living with relatives □ Other (please state) □ Looked After Child □ Subject to a Child Protection Plan □ Adopted First language: Interpreter required? □ Yes □ No If yes, which language? Does the child/young person consider themselves to be transgender? □ Yes □ No Sexual orientation: □ Heterosexual □ Gay □ Lesbian □ Bisexual □ Prefer not to say Does the child / young person have a disability? □ Yes □ No If Yes, Please specify: Does the child / young person have a Visual impairment □ Yes □ No Hearing impairment □ Yes □ No Is the child / young person a Young Carer? □ Yes □ No Name of GP GP surgery name GP surgery telephone number and email address GP surgery address: Ethnicity □ White British □ Irish □ Gypsy or Irish Traveller
□ White and Black Caribbean □ White and Black African □ White and Asian □ Indian □ Pakistani □ Chinese □ Bangladeshi □ Any Asian background □ African □ Caribbean □ Black/Caribbean/African Background □ Arab □ Any other ethnic group – please state □ Any other mixed / multiple ethnic background – please state Religion □ Agnostic □ Atheist □ Baha’I □ Buddhist □ Chinese (Taoist / Confucian) □ Christian □ Hindu □ Humanist □ Japanese (Shinto) □ Jewish □ Jainism □ Muslim □ Pagan □ Rastafarian □ Sikh □ Spiritualist □ Do not wish to disclose □ Other SECTION TWO – PARENT/CARER DETAILS Who holds parental responsibility for the child /young person? Forename Surname Relationship Telephone number: Address Is there any history of parental mental health difficulties and/or history of substance misuse? □ Yes □ No If yes, please provide details: Are there any adult services currently involved? □ Yes □ No If yes, please provide details: SECTION THREE – CHILDREN’S SERVICES Name of Allocated Social Worker or Family Support Worker Children’s Services Team Address Telephone SECTION FOUR - EDUCATION / NOT IN EDUCATION (NEET) Name of School/College: School/College address and telephone number: Home school / Tutor Please give details: SECTION FIVE – MENTAL HEALTH NEEDS AND CONCERNS Reasons for Referral – Please state nature of mental health difficulties, onset, frequency and duration, current presenting risk, interventions tried, impact on child and family, impact on education, and any relevant medical history:
For Basingstoke and Aldershot: North Single Point of Access Hospital Hill Aldershot Hampshire GU11 1AY Winchester, Test Valley, Eastleigh and New Forest: West Hampshire Single Point of Access Ashurst Child and Family Centre Lyndhurst Road Ashurst Southampton SO40 7AR Fareham, Gosport, Havant and Petersfield: South East Hampshire Single Point of Access 1st Floor Osborn Centre Osborn Road Fareham PO16 7ES