Wakefield CAMHS professional referral form | South West Yorkshire Partnership Teaching NHS Foundation Trust

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In crisis
Wakefield CAMHS professional referral form

Home › Service users and carers › In crisis › Wakefield CAMHS professional referral form

Referral criteria

Wakefield CAMHS Single Point of Access referral form professional referral form

For Professionals Supporting Children and Young People’s Mental Health If the child/ young person feels unsafe and at immediate risk to themselves or others in relation to their mental health, please call the REACH crisis team: 01924 316200. (hours 8-8 pm 7 days a week) or call emergency services on 999/111

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Wakefield CAMHS Single Point of Access referral form

Consent(Required)

Referral discussed with child and consent obtained

If aged 14+, child/young person is Gillick competent

Consent obtained from parent/carer with parental responsibility

Date consent obtained(Required)

Day

Month

Year

Referrer details

Name(Required)

Title First Last

Role(Required)

Organisation(Required)

Referrer address(Required)

For return correspondance

Street Address Address Line 2 City Post code

Email(Required)

Date of referral

Day

Month

Year

GP Name(Required)

Practice name(Required)

GP Address

Street Address Address Line 2 City Post code

About the child / young Person

Full name(Required)

First Last

Preferred name

First Last

Date of birth(Required)

Day

Month

Year

NHS number if known

Address

Street Address Address Line 2 City Post code

Does the young person live at home?(Required)

Yes

No

Who does the young person live with(Required)

Grandparents, aunt/uncle, foster carers, residential support workers:

Is the young person a child in care?(Required)

Yes

No

Which local authority are they under the care of?(Required)

Contact number

Country Phone Number

School or nursery name

Contact information if known

First language

Interpreter required?

Yes

No

Gender identity(Required)

Male

Female

Non-binary

Prefer not to say

Other

Ethnicity(Required)

White Welsh / English / Scottish / Northern Irish / British

White Irish

White Gypsy or Irish Traveller

White Any other White background

Any other White background

Mixed White and Black Caribbean

Mixed White and Black African

Mixed White and Asian

Any other mixed background

Indian

Bangladeshi

Pakistani

Chinese

Any other Asian background

Caribbean

African

Any other Black background

Arab

Other ethnic group

Prefer not to say

Other

Disability(Required)

No

Registered disabled

Other

Religion

Background and History

Overview - Relevant background and history(Required)

Significant life events: (bereavement, trauma, housing, separation):

Developmental history: (milestones, educational needs, neurodevelopmental concerns)

Physical health needs / physical symptoms - tummy ache, headaches, current medication

Family history of mental health

Current school support

What current school support is currently offered to parents? Carers, & attendance

Current Concerns and Impact

What’s happening now for the child or young person?(Required)

Frequency: How often do these feelings or experiences happen?(Required)

Intensity: On a scale of 1 (mild) to 10 (overwhelming), how strong are these feelings?(Required)

Duration: When they happen, how long do they last?(Required)

Onset: When were these feelings first noticed and what may have triggered them(Required)

Impact areas where is this affecting the young person?

Tick all that apply

School / college (e.g., attendance, concentration)

Home life (e.g., relationships with family)

Friendships or relationships

Sleep (e.g., difficulty falling or staying asleep)

Eating (e.g., appetite changes)

Are you having feelings in your body- tummy ache, headaches, etc?

Daily routines or self-care

Hobbies, sports, or activities you enjoy

What helps or makes things worse?

Risk and Safety Planning

Suicidal thoughts: Has the young person ever felt unsafe or not wanted to be alive?(Required)

Yes

No

Suicidal thoughts: any current suicidal thoughts, intent, or plans?(Required)

Yes

No

Has the young person ever self-harmed(Required)

Yes

No

Details of self harm(Required)

Does the young person feel safe at home, school, and in their relationships?(Required)

Yes

No

Does the young person ever worry about hurting someone else?(Required)

Yes

No

Safety plan checklist

Please tick items discussed and created in your safety planning ( if risk has been identified by you , please ensure you have safety planned and sought advise accordingly )

Early warning signs

Coping strategies/distraction techniques

Safe environment (removal of means)

Trusted people to talk to (family/friends/professionals)

Contact info for crisis/emergency support (REACH, Samaritans, papyrus etc)

Community/school/home support plan

Goals and hopes

What would the young person like to change or achieve through CAMHS?(Required)

Your view of the situation what do they feel would help

What are the family’s and school’s hopes for support?

Support tried and current involvement

What support has been accessed?

What has already been tried? (e.g. Early intervention services, school support)

Early intervention services, School support, Compass, Early Help, Family Hub, self-help tools

What helped? What didn't?

Agencies currently involved

Early Help

EHCP / SEN Support

Social Care – (name of social worker)

Looked After Child /CIN

Youth Justice Service

FCAMHS

PREVENT

Other

Specify other agency that is involved(Required)

Neurodiversity & developmental differences

Does the young person have any neurodiversity needs?(Required)

Yes

No

Please state(Required)

Is the young person currently under assessment of awaiting referral?(Required)

Yes

No

Have any traits been observed by the child or young person their family, or school?(Required)

Yes

No

Are any reasonable adjustments required to engage in consultations?

Yes

No

Please state(Required)

If the young person has been unable to access services before despite reasonable adjustments, would they be able to access services if significant adaptations made?

Presenting needs(Required)

Low mood / depression

Anxiety (GAD, panic, phobias, OCD)

Self-harm

Suicidal thoughts

Eating concerns / ARFID

Behavioural difficulties / emotion dysregulation

Trauma

Neurodevelopmental concerns (ASC/ADHD)

Unusual experiences

Learning disability

Other

Please state(Required)

Final checks before sending(Required)

Risk assessed and safety planning completed with Child/parent/carer

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Page last updated on: 2^nd December 2025

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