CAMHS Self-referral Form for Child/Young Person

If any of the information that you tell us makes us worried that you are a risk to yourself or other people, or you are at risk from other people, then we would need to link with your parent or carer to talk to them in order to ensure that adults are keeping you safe.

If you feel you are in danger and you think this is an emergency then call 999. If you feel as though you are not in danger but would like to speak to someone urgently then please contact our Crisis Care Line, 24 hours a day 7 days a week, on 0151 293 3577. You may prefer to contact your GP or 111 for their advice.

Alder Hey CAMHS Self-referral Form for Child/Young Person

Alder Hey CAMHS can only accept referrals from Children/Young People and their parents/carers who have a Liverpool or Sefton GP.

Your details

Do you consent to tell us the information we are asking for in this form? *

First name: *

Surname: *

Any previous names:

1st line of address: *

2nd line of address:

Postcode: *

Do you consent for us to send mail to this address? *

We may need to contact you directly, so please provide an up to date, valid contact number

Contact number: *

Date of birth (DD/MM/YYYY): *

Gender

Ethnicity

Languages spoken (please state):

Interpreter required? *

Yes No

Details of your GP

Name of your GP:

1st line of GP address (if known):

Postcode (if known):

Information about your parent(s)/carer(s)

First name:

Surname:

Relationship to you (please state):

Their contact details (address, email, telephone):

Does this person have parental responsibility?

About your education

Name of school:

Address of school (if known):

Postcode (if known):

Year group:

Are you in education/training/work?

Do you have an EHCP (Education and Health Care Plan)?

Are you open to an EHAT?

Are there any other professionals working with you, for example doctors, counsellors, nurses or social workers? (Please stae)

If you have a social worker, can you provide their name?

Can you name any other professionals who you talk to, and do you know their contact details?

Reason for referral

Please let us know why you are making this referral. It might be helpful to include any details of any mental health difficulties you have had in the past as well as how you are feeling right now. The more information you can tell us, the better we can decide on how we can help you.

How long have you been experiencing your difficulties? *

Has anything happened recently to make you ask for help at this time? *

Is there any further information that you think it is important for us to know?

We are part of a CAMHS partnership and sometimes it is not Alder Hey CAMHS who will be the best service for you. If this is the case we might ask one of our CAMHS partners to see you as they might be a better service for you.

I agree for information to be shared with other agencies that might be able to help me. Do you consent for this to happen? *

We will store clinical notes and information about you on a secure database at Alder Hey Hospital. Do you consent to this? *