Referral for Access Assessment into Inpatient Services for Children & Young People PART A: ALL FIELDS TO BE COMPLETED BY CAMHS T3 CLINICAN, EXISTING INPATIENT SERVICE or ADULT CRISIS TEAM Referral Type Emergency Urgent Routine (please circle relevant type) Response in 12 hrs; assessment in Review and response within 48 Review and respond within 1 24 hrs. hrs. week; assessment within 4 weeks The existing clinical team will retain responsibility for patient care until an admission into a CAMHS inpatient placement. ☐ Is there any restriction on sharing information? Yes☐ No If so please give details: Details: Personal Details Full name: Previous surnames: Address: Date of Birth: NHS No: Gender Religion: Ethnicity: Telephone No: First language: Special consideration for communications: CCG: GP name and address: Parent or guardian name: Address: Does the person above have Yes No parental responsibility? Name of person with parental responsibility: Contact telephone number: Legal Status at time of Referral Is the Child: Yes No tick as appropriate Currently detained under the Mental Health Act?If ☐ ☐ yes, what identify below: ☐ ☐ Under Section 136 Living with parent/carer with parental responsibility ☐ ☐ ☐ ☐ Voluntarily accommodated by the Local Authority (s20) Subject to Care Order (s 31) ☐ ☐ If s20 or s31, are they placed in: tick as appropriate Foster Care ☐ ☐ ☐ ☐ Residential Care With Parents ☐ ☐ Is the child subject of: ☐ ☐ Child in need plan Child Protection Plan ☐ ☐
Referral for Access Assessment into Inpatient Services for Children & Young People PART A: ALL FIELDS TO BE COMPLETED BY CAMHS T3 CLINICAN, EXISTING INPATIENT SERVICE or ADULT CRISIS TEAM Referral Type (please circle relevant type) Emergency Response in 12 hrs; assessment in 24 hrs. Urgent Review and response within 48 hrs. Routine Review and respond within 1 week; assessment within 4 weeks The existing clinical team will retain responsibility for patient care until an admission into a CAMHS inpatient placement. Is there any restriction on sharing information? If so please give details: Yes☐ No ☐ Details: Personal Details Full name: Previous surnames: Address: Date of Birth: NHS No: Gender Religion: Ethnicity: Telephone No: First language: Special consideration for communications: CCG: GP name and address: Parent or guardian name: Address: Does the person above have parental responsibility? Yes No Name of person with parental responsibility: Contact telephone number: Legal Status at time of Referral Is the Child: tick as appropriate Yes No Currently detained under the Mental Health Act?If yes, what identify below: ☐ ☐ Under Section 136 ☐ ☐ Living with parent/carer with parental responsibility ☐ ☐ Voluntarily accommodated by the Local Authority (s20) ☐ ☐ Subject to Care Order (s 31) ☐ ☐ If s20 or s31, are they placed in: tick as appropriate Foster Care ☐ ☐ Residential Care ☐ ☐ With Parents ☐ ☐ Is the child subject of: Child in need plan ☐ ☐ Child Protection Plan ☐ ☐
Form-1-Referral-for-Assessment.docx