□ □ □ White and Black Caribbean White and White and Asian Black African □ □ □ □ Indian Pakistani Chinese Bangladeshi □ □ □ □ Any African Caribbean Black/Caribbean/African Background Asian background □ □ Arab Any other ethnic group please state – □ Any other mixed / multiple ethnic background – please state Religion □ □ □ □ □ Agnostic Atheist Baha’I Buddhist Chinese (Taoist / Confucian) □ □ □ □ □ □ Christian Hindu Humanist Japanese (Shinto) Jewish Jainism □ □ □ □ □ Muslim Pagan Rastafarian Sikh Spiritualist □ □ Do not wish to disclose Other SECTION TWO PARENT/CARER DETAILS – Who holds parental responsibility for the child /young person? Forename Surname Relationship Telephone number: Address Is there any history of parental mental health difficulties and/or history of substance misuse? Yes No □ □ If yes, please provide details: Are there any adult services currently involved? Yes No □ □ If yes, please provide details: SECTION THREE CHILDREN’S SERVICES – Name of Allocated Social Worker or Family Support Worker Children’s Services Team Address Telephone SECTION FOUR - EDUCATION / NOT IN EDUCATION (NEET) Name of School/College: School/College address and telephone number: Home school / Tutor Please give details: SECTION FIVE MENTAL HEALTH NEEDS AND CONCERNS – Reasons for Referral – Please state nature of mental health difficulties, onset, frequency and duration, current presenting risk, interventions tried, impact on child and family, impact on education, and any relevant medical history:
□ White and Black Caribbean □ White and Black African □ White and Asian □ Indian □ Pakistani □ Chinese □ Bangladeshi □ Any Asian background □ African □ Caribbean □ Black/Caribbean/African Background □ Arab □ Any other ethnic group – please state □ Any other mixed / multiple ethnic background – please state Religion □ Agnostic □ Atheist □ Baha’I □ Buddhist □ Chinese (Taoist / Confucian) □ Christian □ Hindu □ Humanist □ Japanese (Shinto) □ Jewish □ Jainism □ Muslim □ Pagan □ Rastafarian □ Sikh □ Spiritualist □ Do not wish to disclose □ Other SECTION TWO – PARENT/CARER DETAILS Who holds parental responsibility for the child /young person? Forename Surname Relationship Telephone number: Address Is there any history of parental mental health difficulties and/or history of substance misuse? □ Yes □ No If yes, please provide details: Are there any adult services currently involved? □ Yes □ No If yes, please provide details: SECTION THREE – CHILDREN’S SERVICES Name of Allocated Social Worker or Family Support Worker Children’s Services Team Address Telephone SECTION FOUR - EDUCATION / NOT IN EDUCATION (NEET) Name of School/College: School/College address and telephone number: Home school / Tutor Please give details: SECTION FIVE – MENTAL HEALTH NEEDS AND CONCERNS Reasons for Referral – Please state nature of mental health difficulties, onset, frequency and duration, current presenting risk, interventions tried, impact on child and family, impact on education, and any relevant medical history:
2018-03-29-Hampshire-Specialist-CAMHS-SPA-Referral-Form-Version-09.docx