About the Young Person Name: Also known as: About the Referrer Date of Birth: Name: NHS Number: Job Female Other Male Agency: Ethnicity: Address: School attending: First Language: Postcode: Yes No Interpreter required: Telephone: Pregnant or has Yes No under 1 year of age? Email: : Home Address: Signature: (if not sent by email) Date of Request Postcode: for Service: Method of contact: Date child / young person Post Telephone Mobile last seen by referrer: Postal Address (if different): Is an Help Assessment in place? Postcode: Yes No Unknown If so please attach latest copy and name of lead professional: Young person Telephone: Is an Education & Health Care Plan (EHCP) in place? Mobile: Yes No Unknown If so please attach latest copy and name of lead professional: Parent / Carers names and contact numbers: Is a Child In Need plan in place Yes No Unknown If so please attach latest copy and name of lead worker: If your request for service is to query an eating disorder Height, Weight & Blood Pressure needs taking at the GP Surgery and recording here with the date taken. Is there a Child Protection Plan? Please state any previous height / weight / blood pressure Yes No Unknown If so please recordings and date taken: attach latest copy and name of lead worker: We also suggest at the time of completing this form, you arrange a follow up appointment to review your measurements. Past CAMHS involvement: GP Name: Yes No Unknown GP Address: Who holds parental responsibility for care? GP Post Code: Is the person in the care of the Local Authority? Is person currently on any medication that Yes No would be useful for us to know about?: If yes, please give name of Local Authority responsible for providing care:
About the Young Person Name: Also known as: Date of Birth: NHS Number: Male Female Other Ethnicity: School attending: First Language: Interpreter required: Yes No Pregnant or has under 1 year of age? : Yes No Home Address: Postcode: Method of contact: Post Telephone Mobile Postal Address (if different): Postcode: Young person Telephone: Mobile: Parent / Carers names and contact numbers: If your request for service is to query an eating disorder Height, Weight & Blood Pressure needs taking at the GP Surgery and recording here with the date taken. Please state any previous height / weight / blood pressure recordings and date taken: We also suggest at the time of completing this form, you arrange a follow up appointment to review your measurements. GP Name: GP Address: GP Post Code: Is person currently on any medication that would be useful for us to know about?: About the Referrer Name: Job Agency: Address: Postcode: Telephone: Email: Signature: (if not sent by email) Date of Request for Service: Date child / young person last seen by referrer: Is an Help Assessment in place? Yes No Unknown If so please attach latest copy and name of lead professional: Is an Education & Health Care Plan (EHCP) in place? Yes No Unknown If so please attach latest copy and name of lead professional: Is a Child In Need plan in place Yes No Unknown If so please attach latest copy and name of lead worker: Is there a Child Protection Plan? Yes No Unknown If so please attach latest copy and name of lead worker: Past CAMHS involvement: Yes No Unknown Who holds parental responsibility for care? Is the person in the care of the Local Authority? Yes No If yes, please give name of Local Authority responsible for providing care: