Cumbria Child and Adolescent Mental Health Service (CAMHS)
Referral Form (NCCCG)
INADEQUATELY COMPLETED FORMS AND UNJUSTIFIABLE REQUESTS WILL BE RETURNED TO THE REFERRER

PLEASE NOTE IF THE CHILD/YOUNG PERSON IS NOT SEEN AS PART OF THE REFERRAL, IT WILL NOT BE ACCPETED

IF THERE ARE IMMEDIATE SAFEGUARDING CONCERNS THEN IT IS THE RESPONSIBILITY OF THE REFERRER TO CONTACT THE SAFEGUARDING HUB.

This referral form is for access to services incorporating Primary Mental Health Early Intervention and CAMH Services which are jointly delivered by Cumbria Partnership NHS Foundation Trust and Barnardo’s across Cumbria. Your referral will be reviewed by representatives from both organisations. Onward referral to other agencies will be completed on your behalf where clear consent is included on this form. 	

PATIENT DETAILS: 	                               Referral Date:     	
SURNAME: 
	DOB:  
	PRACTICE:

Practice code:   
Registered GP: 	
FIRST NAME: 
      	AGE:
		
NHS NUMBER:	GENDER: 		
ETHNICITY:		
RELIGION:  		
ADDRESS: 

 		
PHONE:
Home: 
Mobile: 
Work:  	INTERPRETER REQUIRED? 
(if yes, state language including signing)    
YES  NO  	
SCHOOL (if known): 
	Is attendance an issue? 	              
                    DON’T KNOW        YES     NO 	
DISABILITY (if yes, provide details): 								YES     NO 
	
Is the child/young person “looked after” as defined in the Children’s Act 1989?			YES     NO 	
Is the child/young person adopted?								YES     NO 	
Are there safeguarding concerns about the child/young person or family? (if yes, provide details)	YES     NO 

	
Is the child/young person subject to a Child Protection Plan?		   DON’T KNOW          YES     NO 	

OTHER SERVICES / PROFESSIONALS INVOLVED (if known):	
Name	Agency	Contact Tel No	

			
Has an Early Help Assessment been completed?				   DON’T KNOW          YES     NO 	

FURTHER HELPFUL INFORMATION: 	
Does the parent or carer have any known literacy problems? (if yes, provide details)			YES     NO 
	
Do the parents/guardians have parental responsibility?						YES     NO 	
Are the parents/guardians agreeable to the referral?						YES     NO 	
Is the child/young person aware of the referral?							YES     NO 	

REFERRAL DETAILS:	

To guide referrers please consider the following prompt questions:
•	The symptoms you are concerned about including the frequency, and intensity.
•	How long have they experienced the problems?
•	When did the problems start? What was happening at this time?
•	The impact on daily functioning (at home, school, self-care).
•	Any concerns about risk to themselves or others (also complete risk section below)
•	Their family and social circumstances.
•	Details of any safeguarding concerns. 
•	Any physical health concerns. 
•	Any specific learning needs or adaptions that may be required?
•	What help has already been tried.
•	What are the expectations from this referral? What does the young person want?

Details: 

	

SIGNIFICANT MEDICAL HISTORY
Active
Date	Problem	Associated Text	Date Ended	

Significant Past
Date	Problem	Associated Text	Date Ended	

 

MEDICATION
Acute
Drug	Dosage	Quantity	Last Issued On	

Repeat
Drug	Dosage	Quantity	Last Issued On	

 
ALLERGIES:   

RISK ASSESSMENT:	
Are there any issues that place this young person or others at risk?(if yes, provide details)		YES     NO 

Prompt questions:
If yes, specifically what risk? 
When did this start? Is it historic or current risk? 
Severity? Frequency? Duration? 
What has been done to manage the risk? 
Can the Young Person be kept safe until their CAMHS appointment?

Details: 

If you are concerned about a young person having a suicide plan and intent to act please contact the Single Point of Access on 0300 123 9015. If there is an imminent risk to life please contact the emergency services.
If you have a serious concern about the young person being at risk from others please contact the Safeguarding Hub on 0333 240 1727.

	

AGREEMENT TO REFERRAL:	
The information on this form will be used to assess the emotional and mental health needs of the referred child/young person. Sometimes we may be able to re-direct the referral to a more appropriate service if consent is obtained to share the information with other agencies.
Have the parents/guardians given consent to allow CAMHS to share information as specified above?	YES     NO 	

REFERRER DETAILS:	
REFERRER’S NAME: 

REFERRER’S DESIGNATION:

REFERRER’S ORGANISATION: 

TEL: 	
SIGNATURE:	DATE: 	

Note to provider: this referral form has been standardised locally in line with the required NHS minimum requirements and guidance from Information Governance. Please email primis@ncic.nhs.uk with any proposed amendments to the form.

CEDS Referral Form Triage Prompt Questions

Does the young person present with a suspected eating disorder?
Do they appear to have body image distortion? Are they deliberately attempting to lose weight in an unhelpful way, particularly if weight loss is not clinically indicated? Include an eating disorder diagnosis if this has been given. 	

	
What is the young person’s current weight and height? And do they have a history of weight loss? If so, please give details including the current rate of weight loss. 	

	
Is the young person currently restricting their food or fluid intake? If yes, please give details. If malnutrition or dehydration is suspected, please include details of any physical health symptoms	

	
Does the young person report binging (eating large volumes of food in a short space of time) episodes? If yes, please give details. 	

	
Does the young person report any compensatory behaviours to control or reduce their weight – these include vomiting, laxatives, excessive exercise, diet pills? If yes, please give details. 	

	
For any suspected eating disorder, an assessment of physical health risk is essential. Please consider when the young person last saw their GP and consider requesting an urgent appointment to check the following according to Junior MARSIPAN Guidelines: blood biochemistry (full FBC’s, U’s and E’s, Potassium, Magnesium, Phosphate, LFT’s), blood pressure standing and sitting, temperature, pulse rate, weight and height and attaching these results to the referral. Seeks guidance from CEDS clinicians if you are unsure. 	

SEND REQUEST TO:	Tel Number	Email	
West Cumbria: 	Park Lane Clinic, Park Lane, Workington, Cumbria, CA14 2RR	01900 705800	CMB-CAMHSAdmin@cntw.nhs.uk
	
East Cumbria	Fairfield Centre, Carleton Clinic, Cumwhinton Drive, Carlisle, Cumbria CA1 3SX	01228 603017	CMB-CAMHSAdmin@cntw.nhs.uk