North Lincolnshire CAMHS online referral form Request for advice and/or support Is the request urgent? YesNo Is the person currently suicidal with intent? YesNo If "Yes", please follow up this referral with a telephone call (01724 408460). Also please ensure that you work with the person to implement a safety plan. Is informed consent given? YesNo Consent given by: Date consent given: If the person is over 14 years old, have they given consent? YesNoN/A Please note we cannot accept any requests for advice or support without consent. Is this request for professional consultation and advice? YesNo Is this request for specialised mental health support? YesNo Person's details First name: Last name: Preferred name: Date of birth: NHS number: Gender: —Please choose an option—FemaleMaleIndeterminateDo not wish to specify Address line 1: Address line 2: Town/city: Postcode: Main telephone number: Alternative telephone number: Preferred contact method: TelephoneLetterText message Religion: Ethnicity: Interpreter required? YesNo If "Yes", please state language: GP surgery: School or college attended: —Please choose an option—Baysgarth SchoolBrumby OutwoodFoxhills Outwood AcademyFrederick Gough SchoolHuntcliff Comprehensive SchoolJohn Leggott Sixth Form CollegeMelior Community AcademyNelthorpe SchoolNorth Lindsey CollegeRMPLCSouth Axholme AcademySt Bedes AcademyThe Axholme AcademyVale AcademyWinterton Community AcademyNot listed Does the person have an identified learning disability? YesNo Education healthcare plan: In placeIn progressNone Legal status (e.g. LAC): YesNo Child protection plan or child in need: YesNo Early help support: YesNo Neurodevelopmental diagnosis? ASDADHDAwaiting assessmentN/A Parent or guardian details (if person is under 16 years old) First name: Last name: Relationship to person: Address line 1: Address line 2: Town/city: Postcode: Main telephone number: Alternative telephone number: Preferred contact method: TelephoneLetterText message Referrer's details First name: Last name: Profession: Address line 1: Address line 2: Town/city: Postcode: Telephone number: Email Address: Reasons for request for support/advice Symptoms/presenting problems Eating disorders: HistoricalCurrentN/A Anxiety: HistoricalCurrentN/A Depression: HistoricalCurrentN/A Post-traumatic stress disorder (PTSD): HistoricalCurrentN/A Obsessive compulsive behaviours: HistoricalCurrentN/A Phobias: HistoricalCurrentN/A First episode psychosis (suspected): HistoricalCurrentN/A Risk factors Suicidal thoughts: YesNo Harm to self: YesNo Harm to others: YesNo What are we worried about and for how long? 500 What is working well? 250 What support has already been accessed? 250 What do all parties think will help? 250 What plan is in place to keep the person safe? 250 What is the expectation from all parties of this referral? 250