Please give details of any known medications the Child/Young Person is currently taking. Child/Young Person: Please give details of what the child/Young Person would like to happen as a result of this referral. Parent/Carer: Please give details of what the parent/carer would like to happen as a result of this referral. Referrer: In making this referral, what outcomes are you anticipating for the Child/Young Person/Family? Section 10 Summary of risks: Recent Past Historical Past Current Child/ Young Person (last 2 weeks) (last 6 months) (over 6 months) Self-Harm Harm to others Suicidal thoughts/ intentions Physical/sexual/ emotional abuse Significant medical needs/ Disability Parent/ Environment Parental mental illness Domestic violence Parenting difficulties For Each Risk Identified, Please Provide Details:
Please give details of any known medications the Child/Young Person is currently taking. Child/Young Person: Please give details of what the child/Young Person would like to happen as a result of this referral. Parent/Carer: Please give details of what the parent/carer would like to happen as a result of this referral. Referrer: In making this referral, what outcomes are you anticipating for the Child/Young Person/Family? Section 10 Summary of risks: Child/ Young Person Current (last 2 weeks) Recent Past (last 6 months) Historical Past (over 6 months) Self-Harm Harm to others Suicidal thoughts/ intentions Physical/sexual/ emotional abuse Significant medical needs/ Disability Parent/ Environment Parental mental illness Domestic violence Parenting difficulties For Each Risk Identified, Please Provide Details:
NELFT-CYPMHS-referral-form.docx