"*" indicates required fields Please note that currently we only accept online referrals from professionals. * REQUIRED I confirm I am a professional About this formThis form should be completed while logged into a secure work computer which only you have access to. We are required to register the full demographic details (including area of residency, GP details and NHS number) of all referrals. Please include this information in your referral otherwise we will need to return this form to you prior to triage. We are required to register the full demographic details (including area of residency, GP details and NHS number) of all referrals. Please include this information in your referral otherwise we will need to return this form to you prior to triage.Section 1: ConsentReferrals cannot be accepted without the consent of the child or parent/guardian. Please select applicable consent. Consent given by: * REQUIRED Child Parent/Carer Both Consent to share with other agencies: Sometimes we may find that CAMHS is not the best service for the young person and there may be another organisation that is better suited to their needs, e.g. Let's Talk Well, Young Gloucestershire. In this case it can be helpful to contact other agencies that may be able to help them.Does child/young person or parent/carer agree to information being shared between agencies? * REQUIRED Yes No Have you considered other agencies to offer support? * REQUIRED Yes No Section 2: Referrer detailsReferrer name * REQUIRED First Last Referrer job title * REQUIREDReferrer telephone number * REQUIREDReferrer email * REQUIRED Referrer location/address:Section 3: About the child/young personYoung person's name * REQUIRED First Last Preferred nameFamily name if different to theirsDate of birth * REQUIRED DD slash MM slash YYYY NHS numberIf knownEthnicity * REQUIREDWhat gender does the young person identify as? * REQUIRED Male Female Other Prefer not to say Preferred nounsFirst language * REQUIREDInterpreter required? * REQUIRED Yes No Address * REQUIRED Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Preferred contact number * REQUIREDAlternative contact numberHas the young person been a resident of the UK for 6 months or longer? * REQUIRED Yes No Education * REQUIRED Pre-school School College Not in Education, Employment, or Training (NEET) Homeschooled Start date * REQUIREDDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GP Surgery and GP NameHealth visitor/school nurseIf knownIs the child/young person in care/special guardianship? * REQUIRED Yes, Child in Care (Looked After Child) Yes, Special Guardianship No About the principle parents/main carersDoes the child/young person have a main carer? * REQUIRED Yes No Name * REQUIRED First Last Relationship * REQUIREDContact details * REQUIREDParental responsibility * REQUIRED Yes No Is there any additional information you would like to add?Reason for referralPlease let us know why you are making this referral, including details of any previous or current mental health problems.In this section you might like to include some of the following: A description of any mental health difficulties the young person might be having. How long have these been affecting them? What impact have these had on them and have they had any impact on their family, school work or friends? Have there been any big family events or illnesses recently?The more information you include, will help us determine the most appropriate Parent Support Group to allocate. The Parent Support groups we currently provide, for external referral are: Parents Plus - ADHD, Children programme, Parents Plus- SEND Programme , for parents of children with Special Education Needs and/or Learning Disability, Parenting through Partnership – A neuro-affirming approach to Stress and Anxiety, for parents of children who are experiencing anxiety irrespective of neurotype.Please describe any mental health difficulties they might be having * REQUIREDe.g. worries, sadness, anger, changeable moods or feelings, self-harm etc.How long has this been affecting them? * REQUIRED Less than a month 1 - 5 months 6 - 12 months Over a year What impact have these had on them and have they had any impact on their family, school work or friends? * REQUIREDHas anything happened recently to make them seek help at this time? * REQUIREDHave there been any big family events or illnesses recently? * REQUIREDIs there any further information that you/they think we should know? * REQUIREDAre there any concerns about the young persons eating? * REQUIRED Yes No What support are the family/young person wanting from a Parent Support Group?Supporting informationPlease attach any additional information you feel is relevant to this referral.File Drop files here or Select files Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 64 MB, Max. files: 3. Other professionalsIs the young person currently working with, or have they worked with, any other agencies, people or organisations, including their school? Yes No Agency detailsName of organisation/agency/individual * REQUIREDStart date or best guess * REQUIREDCurrent involvement? * REQUIRED Yes No Please give details of length and nature of their support. * REQUIREDFor example, 6 sessions with TIC+ onlineAre you happy for us to get in contact with this agency? * REQUIRED Yes No Contact email or telephone number for agencyAdd another agency? Yes No Agency details 2Name of organisation/agency/individual * REQUIREDStart date or best guess * REQUIREDCurrent involvement? * REQUIRED Yes No Please give details of length and nature of their support. * REQUIREDFor example, 6 sessions with TIC+ onlineAre you happy for us to get in contact with this agency? * REQUIRED Yes No Contact email or telephone number for agencyAdd another agency? Yes No Agency details 3Name of organisation/agency/individual * REQUIREDStart date or best guess * REQUIREDCurrent involvement? * REQUIRED Yes No Please give details of length and nature of their support. * REQUIREDFor example, 6 sessions with TIC+ onlineAre you happy for us to get in contact with this agency? * REQUIRED Yes No Contact email or telephone number for agencyCAPTCHA