CAMHS Infant Mental Health Pathway – Professionals Request for Help Complete this form if you are a professional requesting help from the CAMHS Infant Mental Health Pathway Name of child / young person(Required)Date of birth(Required) DD slash MM slash YYYY Address Street Address Address Line 2 City Post Code AgeNHS NumberTelephone number – homeTelephone number – mobileEmailEthnicityInterpreter required Yes No Home language spokenMother's nameParental responsibility Yes No Employment statusFather's nameParental responsibility Yes No Employment statusMarital statusWho does the child reside with?Other adults with parental responsibilityName of person completing formJob titleEmailGP surgeryHealth visitorChild protection plan Yes No Child in need plan Yes No Social workerEarly years settingOutline of cause of concern. Please give as much detail as possible.Summary of support to dateRelevant background information – outline of family history / relationshipsConsent to share informationWe would like your consent to contact any agencies that are currently involved or who we consider may be of help. We may also want to contact other agencies that know you, such as your school or GP, to help us provide a better service to you. We will ensure that your personal information is kept confidential, unless there are specific concerns that require us to share your details, e.g. child protection concerns. You will be told of this.Please tick if you are agreeable to consenting to use the CAMHS appointment reminder service. This means that you will receive an appointment reminder via mobile text message. Yes No If yes please provide the mobile number which you wish to receive your appointment reminder toI agree to information being shared between agencies to help me/my childName of child / young personSignature of principal parent/main carerCompletion of this field will act as the signature of the principal parent/main carerDate DD slash MM slash YYYY If no consent sought please state whyPlease indicate here any agencies / persons you would not want us to contactPlease provide any relevant background informationInfant Mental Health Pathway: Consent to Share InformationGuidance for Patients & Service Users. We (Livewell Southwest Infant Mental Health Pathway (IMH)) often receive information about children, babies, and their parents and families. As we are a 0-5 service most information will be recorded on your child’s record on SystmOne (our electronic record keeping system), the referral will also be in the child’s name. This means that other health providers who use system one, such as health visitors and GP’s, will have access to the information recorded. In order to respect your privacy and protect the information you share with the IMH anything that is disclosed which pertains solely to you (parents/carers) will be recorded on your clinical record on SystmOne. Reference to this recording will be made on the child’s record but there will not be a detailed entry unless it is necessary due to child safety. For example it may say, “during the appointment we discussed the relationship that mum had with her own parents – (please see mother’s record if clinically relevant)”. There are rare occasions when a parent does not have a SystmOne record (for instance if your GP doesn’t use this system), therefore the IMH will need to open a record in your name. Your SystmOne record forms part of your total health record. You may request to see your current IMH record from your health professional. Alternatively you can ask for a copy of all the clinical information that is held in your Livewell Southwest health record by writing to the Data Disclosure Team, Hatfield House, Burrington Way, PL5 3LZ. Livewell Southwest can only provide information related to services provided by us, which will not necessarily constitute your full health record. In addition, any information about any third parties will be removed before you are given a copy of your record. Once we have opened your SystmOne record we may be able to view information recorded by other services you may be involved with, such as your GP, CMHT, Podiatrist etc. While our staff will not actively look at this information it may be on screen, and in cases where there are significant concerns about child safety we may be required to look at your information. There are occasions when it may be helpful to liaise with other services you are involved with e.g. perinatal team, CMHT, in these cases we will endeavour to seek your permission on this matter. By information sharing in this way we can provide a better service to you and your child. However if you do not wish to share information between these organisations please let your health professional know and this can be stopped. However some information related to risk and child safety might still be shared. In the future your child may wish to access his or her own health record and having the information related to you, recorded in your own record will prevent any information that you may not wish to be shared with your child in that manner from reaching them. For antenatal patients only: While you are seen antenatally (before baby is born) the referral to IMH will be in your name and all recording of appointments will go on your health record. Once your child is born, if you are still open to IMH, the referral in your name will be closed and the case will be reopened in your child’s health record. Please read above to understand the full details around consent to share information.