CAMHS Request for Help

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)

Address

Street Address Address Line 2 City Post Code

Age

NHS number (if known)

Telephone number – home (please say who it belongs to – parent/young person)

Telephone number – mobile (please say who it belongs to – parent/young person)

Who is filling this form in?

Today's date

What school/college do you go to?

Who should we speak to in school/college?

GP surgery

Ethnicity

Parent/carer name

Parent/carer address

Street Address Address Line 2 City Post Code

Who has parental responsibility?

Telephone number

Who is currently involved with you/in your young person's care?

If you answered other to the above, please specify

Why would you like help from CAMHS? Please give the reasons for your request

What outcomes/goals would you like to achieve if you were helped by CAMHS?

Is there any other important information you would like to share to help us understand you/your young person?

Have you/your young person previously been involved with CAMHS?

If we need to know more about you/your young person how would you like us to contact you?

Telephone

Post

Are there any current/past child protection or risk issues such as:

If you answered other to the above, please specify

If you ticked any of the child protection or risk issues above, please provide further details in regards to concerns raised

Consent to share information

Consent: 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 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 agreeing to use the CAMHS text reminder service. This will remind you of day and time of your appointment.

Yes

If yes please provide the mobile telephone number

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 person

Name of principal parent/main carer(Required)

Completion of this field will act as the signature of the principal parent/main carer

Date