Email* completed referrals to - 0300 304 0050 Consultation line *Disclaimer: Please be aware that sending by email from iCloud, Gmail, Hotmail, Live, Yahoo or other private email accounts to NHS.net is not secure. If you would prefer to send the referral form via post please send it to the relevant postal address given in Section 8 Criteria’ ‘Referrals Hampshire Specialist Referral (please refer to Section 8 for referral criteria) Name of CAMHS Clinician, if referral is taken over the phone: SECTION ONE YOUNG PERSON DETAILS – Forename Surname Also Date of Birth known as Gender NHS No. Address at Landline / home telephone number which the child/young person is currently living Parent’s/Carer’s person mobile number mobile number Is the Child / Young Person: (tick all that apply) – □ □ □ Living Living with relatives Other (please state) with parents □ □ □ Looked Subject to a Child Protection Plan Adopted After Child First language: □ □ Interpreter required? Yes No If yes, which language? Does the child/young person consider Sexual orientation: themselves to be transgender? □ □ Heterosexual Gay □ □ Yes No □ □ □ Lesbian Bisexual Prefer not to say Does the Does the child / young person have a Is the child / young person a Young Carer? child / □ □ □ □ Visual impairment Yes No Yes No young □ □ Hearing impairment Yes No person have a disability? □ □ Yes No If Yes, Please specify: Name of GP surgery GP name GP surgery GP surgery telephone address: number and email address Ethnicity □ □ □ White British Irish Gypsy or Irish Traveller
Email* completed referrals to Consultation line - 0300 304 0050 *Disclaimer: Please be aware that sending by email from iCloud, Gmail, Hotmail, Live, Yahoo or other private email accounts to NHS.net is not secure. If you would prefer to send the referral form via post please send it to the relevant postal address given in Section 8 ‘Referrals Criteria’ Hampshire Specialist Referral (please refer to Section 8 for referral criteria) Name of CAMHS Clinician, if referral is taken over the phone: SECTION ONE – YOUNG PERSON DETAILS Forename Surname Also known as Date of Birth Gender NHS No. Address at which the child/young person is currently living Landline / home telephone number person mobile number Parent’s/Carer’s mobile number Is the Child / Young Person: (tick all that apply) – □ Living with parents □ Living with relatives □ Other (please state) □ Looked After Child □ Subject to a Child Protection Plan □ Adopted First language: Interpreter required? □ Yes □ No If yes, which language? Does the child/young person consider themselves to be transgender? □ Yes □ No Sexual orientation: □ Heterosexual □ Gay □ Lesbian □ Bisexual □ Prefer not to say Does the child / young person have a disability? □ Yes □ No If Yes, Please specify: Does the child / young person have a Visual impairment □ Yes □ No Hearing impairment □ Yes □ No Is the child / young person a Young Carer? □ Yes □ No Name of GP GP surgery name GP surgery telephone number and email address GP surgery address: Ethnicity □ White British □ Irish □ Gypsy or Irish Traveller
2018-03-29-Hampshire-Specialist-CAMHS-SPA-Referral-Form-Version-09.docx