Rotherham 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 (01709 304808). 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:

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:

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