Request for help (Wirral CAMHS) :: Cheshire and Wirral Partnership NHS Foundation Trust

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Request for help (Wirral CAMHS)

Name of young person Required

Date of Birth Required

Sex Required

If you answered Other to the previous question, please specify using full terminology

Ethnicity Required

If you answered Other to the previous question, please specify using full terminology

NHS Number - Please enter the young person's NHS number. This can usually be found on any correspondence from the hospital

Name of parent/carer Required

Name of person with parental responsibility (if different from above)

Young person's home address Required

Address 1

Address 2

City

Country

County

Postal Code

Main contact number of parent/carer or young person (if over 16) Required

Email address of parent/carer or young person (if over 16 Required

Safeguarding status of young person Required

Name of person requesting help/advice Required

Address of person requesting help/advice Required

Address 1

Address 2

City

Country

County

Postal Code

Phone number of person requesting help/advice Required

Email of person requesting help/advice Required

What is your relationship to the young person or are you the young person yourself? (Please note we can only accept self referrals from young people aged 16+) Required

If you are not the parent/carer or young person, do you have consent from the young person and their parent/carer for this request for help? Required

Name of school/college Required

Are there any difficulties with educational attendance? Required

Are there are difficulties with educational attainment? Required

Would you consider the young person to have special educational needs? Required

Does the young person have an Education Health Care Plan (EHCP)? Required

Does the young person have a disability? Required

If you answered yes to the above, please provide further information

Name of GP (if known)

Name of surgery Required

Is the young person pregnant? Required

Is the young person open to the Youth Offending Service? Required

Has the young person already received support from another organisation? If yes, please give details Required

If there is concern about the person’s weight or of a possible eating disorder? If yes, please give their height and weight Required

Primary Reason for Referral Required

Have there been any changes to the young person's sleep pattern? e.g. have they been sleeping too much or too little? Required

Have there been any changes to the young person's appetite?

e.g. is it smaller, larger or has it altered recently? If they are displaying eating concerns are they restricting the amount they eat, when and what are they eating, what is their current weight and height? Are they using laxatives or being sick after meals? Has their exercise increased?

Have there been any changes to the young person's appetite? Required

Have there been any changes to the young person's mood?

It might help to use a rating scale of 0 to 10, (0 unhappy 10 happy). Is this a new presentation? Do they seem more anxious? When and with whom?

Have there been any changes to the young person's mood? Required

Has the young person displayed any signs of self-harm? If so, what type, when does this happen, how often, is treatment ever required etc. Required

Please provide the details of any significant others e.g family members or other agencies involved (Social Care/ YOS etc) involved. Please provide as much detail as possible e.g. names/date of birth/relationship to young person Required

Has the young person expressed any suicidal thoughts, worries or behaviours? If yes, explore with your young person when these happen and what they think they might plan to do? Required

How is school or college going? Is the young person falling behind, have school raised concerns or offered support? Required

Has the young person withdrawn from usual social activities? Required

Have there been any big events in the young person’s life? Anything that might have upset or frightened them? If yes, what and when was this? Required

Please include anything else you think might help us understand the young person’s presentation; unusual behaviours, new habits, seeing or hearing sounds, voices or figures etc. Required

For how long have the problems you described affected the young person’s life? Required

Please list any family members or other agencies involved in the young person’s life. Please include name/age/relationship to young person Required

Please give any other details that you think might be relevant

This could include some of the following (this is not an exclusive list): family separation, mental health difficulties of the parent / carer, drug or alcohol use by parent / carer or young person, relationship difficulties, physical health problems, witnessed or experienced domestic violence,experienced physical, emotional or sexual abuse, questioning gender identity etc.

Please give any other details that you think might be relevant

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Return to Services in Wirral

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