Referrer's name(Required) First Last Referrer's address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code Referrer's telephone number(Required)About the referralName of person being referrered(Required) First Last What is their date of birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is the name of their parent/carer(Required) First Last What is the child's NHS number(Required)You can look up NHS numbers here www.nhs.uk/nhs-services/online-services/find-nhs-numberRelationship of their parent/carer(Required)Parent/carer's phone number(Required)Who does the child live with(Required)Who has parental responsibility for the child(Required)Are they a Child in Care?(Required) Yes No Does the child have an EHCP?(Required) Yes No To support the referral screening of Learning Disability eligibility we kindly request you provide a copy of the child’s EHCP.Max. file size: 64 MB. Is the parent/carer of the child aware of this referral?(Required) Yes No Education placement details(Required)Current diagnosis information, including level of learning disability (if known):(Required)Please give details of any previous or current professional involvement:(Required)PaediatricianSocial WorkerOTContinenceOtherReason for referralPlease give as much information as possiblePresenting situation and behaviour (current)(Required)Have there been any recent changes?(Required)Please include details of changes in behaviours, breakdown of relationships, bereavement, hospital admission, moving house etc.Support(Required)Please include support the family have either from family or funded supportDo you have any safeguarding concerns(Required)Current risk information(Required)Including harm to self and othersInformation for lone working(Required)Please detail any risks to staff when visiting e.g. dogs, weapons etcWhat are your expectations of this referral and the involvement of LD CAMHS(Required)Please upload any supporting documentsMax. file size: 64 MB. CAPTCHA