Youth-Mental Health Referral Form (12yrs-24yrs)

Youth-Mental Health Referral Form

We are primarily an online service for youth, and we can connect with youth in a variety of flexible ways including phone, video, and text counselling. Depending on location and availability, there is also capacity for in person services.

Name *

Address *

Phone number *

Date of birth *

Age *

email *

Gender *

Ethnicity *

GP/Medical Centre *

Parent/Guardian's name and contact details

NOTE:If the young person is over 16 years old their parents/guardians do not need to be involved.

Yes

If the young person is under 16 years old, it is important that the parent or guardian is aware of the referral unless under exceptional circumstances this is not in the best interest of the young person. Are the parents/guardians aware of this referral?

Yes

Referrer name and details *

Has CAMHS been involved?

Yes

Provide brief summary of when CAMHS was involved, how long for, treatment recieved,and approximate discharge date.

Note: If this referral is coming from CAMHS directly a full discharge letter must accompany this referral.

Please provide appropriate contact information if young person does not wish parents to be involved.

Are you at risk to yourself

Yes

If yes, please provide details: ( if self-harming for example, please let us know here)

Are you having suicidal thoughts/Plan? Please use the box below to provide further information( including any previous suicide attempts)

Please provide as much background information as possible, why you are referring into our mental health service, and what you would like to get out of the service, e.g goals for counselling. Please make sure you have included the main reason for request clearly.

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