CAMHS Professional Request for Help Complete this form if you are a professional requesting help from CAMHS Early Help Pathway If you are contacting CAMHS because you or a young person you know is in crisis, please call First Response on NHS 111 (select the mental health option) for 24/7 support.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 number (if known)EthnicityTelephone number – home (please say who it belongs to – parent/young person)Telephone number – mobile (please say who it belongs to – parent/young person)Email Request for involvement from:Date of request for involvement DD slash MM slash YYYY Education settingContact in education settingParent/carer nameParent/carer contact numberAgencies involved and current support School PSA School Nursing Service Child Development Centre Kooth Young Devon Social Care The Zone MAST Communication Interaction Team Other If you answered other to the above, please specifyPresenting mental health concern and why you would like help from CAMHS. Please provide as much detail as possible.Previous CAMHS involvement and outcomes:How do you think CAMHS could support the child/young person? Please give as much detail as possible.Are there any current/past child protection or risk issues such as: Self harm Suicidal ideation Domestic abuse Housing Known historical abuse Risk of exclusion from education Bullying Parental mental health English as additional language Risk of sexual exploitation Risk of radicalisation Other Please provide details if you have ticked any of the boxes aboveConsent to share informationConsent: This means you are agreeing to share personal information. We 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, GP, Excellence Cluster or MDT Access 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 agreeing to use the CAMHS text reminder service. This will remind you of day and time of your appointment. Yes No If yes please provide the mobile telephone numberPlease indicate your preferred method of contact Email SMS Telephone I agree information being shared between agencies to help me/my child:Name of child/young person(Required)Completion of this field will act as the signature of the young personName of principal parent/main carer(Required)Completion of this field will act as the signature of the principal parent/main carerDate DD slash MM slash YYYY Please indicate here any agencies / persons you would not want us to contact