Child and Adolescent Mental Health Service (CAMHS) Ealing CAMHS Hammersmith & Fulham CAMHS Hounslow CAMHS 48 Glenthorne Road of Hounslow Centre for Health 1 Armstrong Way Hammersmith 92 Bath Road Southall London Hounslow Middlesex W6 0LS TW3 3EL UB2 4SA Tel: 020 8483 1979/77/40/44 Tel: 020 8630 2050 Fax: 020 8483 1941 Fax: 020 8354 8654 Tel: 020 8354 8160 Office Mobile: 07792 782924 Office Mobile: 897642 Fax: 020 8354 8391 Office Mobile: 07808 897641 E-mail: E-mail: wlm-tr.hfcamhs@nhs.net E- mail: Referral form Please complete this form and send it to your local CAMHS. Urgent referrals should be We are required to register the full postcode, GP details and NHS number of all referrals. Please include this information in your referral. Child/Young Person and Family Details: Priority Routine Urgent - Details: Date of <Todays date> i.e. any dates to avoid as patient may be Referral Appt dates to avoid away/unavailable: Child/Young Person (Patient) Referrer Name <Patient name> Name <Sender Name> NHS No <NHS number> GMC <Referrals Out> DOB <Date of Organisation <Organisation Details> Address <Patient Address> Address <Organisation Address> Organisation Home <Patient Contact Details> <Organisation Details> code (if Telephone applicable) Mobile / <Patient Contact Details> Telephone <Organisation Details> Alternative <Patient Contact Details> <Organisation Details> Email Fax Gender <Gender> Email (NHS) @nhs.net ONLY to complete if referrer above Ethnicity <Ethnicity> GP Details NOT GP - e.g. GP Practice Name & Address & Contact Numbers Main <Main spoken Language Interpreter required? No Yes - Spoken language>
Child and Adolescent Mental Health Service (CAMHS) Ealing CAMHS 1 Armstrong Way Southall Middlesex UB2 4SA Tel: 020 8354 8160 Fax: 020 8354 8391 Office Mobile: 07808 897641 E- mail: Hammersmith & Fulham CAMHS 48 Glenthorne Road Hammersmith London W6 0LS Tel: 020 8483 1979/77/40/44 Fax: 020 8483 1941 Office Mobile: 07792 782924 E-mail: wlm-tr.hfcamhs@nhs.net Hounslow CAMHS of Hounslow Centre for Health 92 Bath Road Hounslow TW3 3EL Tel: 020 8630 2050 Fax: 020 8354 8654 Office Mobile: 897642 E-mail: Referral form Please complete this form and send it to your local CAMHS. Urgent referrals should be We are required to register the full postcode, GP details and NHS number of all referrals. Please include this information in your referral. Child/Young Person and Family Details: Priority Routine Urgent - Details: Date of Referral <Todays date> Appt dates to avoid i.e. any dates to avoid as patient may be away/unavailable: Child/Young Person (Patient) Referrer Name <Patient name> Name <Sender Name> NHS No <NHS number> GMC <Referrals Out> DOB <Date of Organisation <Organisation Details> Address <Patient Address> Address <Organisation Address> Home Telephone <Patient Contact Details> Organisation code (if applicable) <Organisation Details> Mobile / Alternative <Patient Contact Details> Telephone <Organisation Details> Email <Patient Contact Details> Fax <Organisation Details> Gender <Gender> Email (NHS) @nhs.net Ethnicity <Ethnicity> GP Details ONLY to complete if referrer above NOT GP - e.g. GP Practice Name & Address & Contact Numbers Language Interpreter required? No Yes - Main Spoken <Main spoken language>