Form Page | Gloucestershire Health and Care NHS Foundation Trust

"*" indicates required fields

Please note that currently we only accept online referrals from professionals. * REQUIRED

I confirm I am a professional

About this form

This 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: Consent

Referrals 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. Teens in Crisis, 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

Have you considered other agencies to offer support? * REQUIRED

Yes

Section 2: Referrer details

Referrer name * REQUIRED

First Last

Referrer job title * REQUIRED

Referrer telephone number * REQUIRED

Referrer email * REQUIRED

Referrer location/address:

Section 3: About the child/young person

Young person's name * REQUIRED

First Last

Preferred name

Family name if different to theirs

Date of birth * REQUIRED

DD slash MM slash YYYY

NHS number

If known

Ethnicity * REQUIRED

What gender does the young person identify as? * REQUIRED

Male

Female

Other

Prefer not to say

Preferred nouns

First language * REQUIRED

Interpreter required? * REQUIRED

Yes

Address * REQUIRED

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Preferred contact number * REQUIRED

Alternative contact number

Has the young person been a resident of the UK for 6 months or longer? * REQUIRED

Yes

Education * REQUIRED

Pre-school

School

College

Not in Education, Employment, or Training (NEET)

Homeschooled

Start date * REQUIRED

GP Surgery and GP Name

Health visitor/school nurse

If known

Is the child/young person in care/special guardianship? * REQUIRED

Yes, Child in Care (Looked After Child)

Yes, Special Guardianship

About the principle parents/main carers

Does the child/young person have a main carer? * REQUIRED

Yes

Name * REQUIRED

First Last

Relationship * REQUIRED

Contact details * REQUIRED

Parental responsibility * REQUIRED

Yes

Is there any additional information you would like to add?

Reason for referral

Please 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:

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: Supporting Your Anxious Child. W.E.B.S (for parents of children with SEND) parent support group. Parents Plus - ADHD, Children programme

Please describe any mental health difficulties they might be having * REQUIRED

e.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? * REQUIRED

Has anything happened recently to make them seek help at this time? * REQUIRED

Have there been any big family events or illnesses recently? * REQUIRED

Is there any further information that you/they think we should know? * REQUIRED

Are there any concerns about the young persons eating? * REQUIRED

Yes

What support are the family/young person wanting from a Parent Support Group?

Supporting information

Please attach any additional information you feel is relevant to this referral.

File

Drop files here or

Accepted file types: jpg, gif, png, pdf, docx, Max. file size: 64 MB, Max. files: 3.

Other professionals

Is the young person currently working with, or have they worked with, any other agencies, people or organisations, including their school?

Yes

Agency details

Name of organisation/agency/individual * REQUIRED

Start date or best guess * REQUIRED

Current involvement? * REQUIRED

Yes

Please give details of length and nature of their support. * REQUIRED

For example, 6 sessions with TIC+ online

Are you happy for us to get in contact with this agency? * REQUIRED

Yes

Contact email or telephone number for agency

Add another agency?

Yes

Agency details 2

Name of organisation/agency/individual * REQUIRED

Start date or best guess * REQUIRED

Current involvement? * REQUIRED

Yes

Please give details of length and nature of their support. * REQUIRED

For example, 6 sessions with TIC+ online

Are you happy for us to get in contact with this agency? * REQUIRED

Yes

Contact email or telephone number for agency

Add another agency?

Yes

Agency details 3

Name of organisation/agency/individual * REQUIRED

Start date or best guess * REQUIRED

Current involvement? * REQUIRED

Yes

Please give details of length and nature of their support. * REQUIRED

For example, 6 sessions with TIC+ online

Are you happy for us to get in contact with this agency? * REQUIRED

Yes

Contact email or telephone number for agency

CAPTCHA