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Wakefield CAMHS online referral form

Home › Wakefield CAMHS online referral form

Wakefield CAMHS online referral form

Contacting and getting support, treatment or an appointment with the Wakefield CAMHS team is known as making a ‘referral’.

Parents and carers of children and young people and young people aged 16 and 17 alongside professionals can contact the Wakefield CAMHS team directly for support. You can contact the team by completing this online referral form, or by calling the team directly Monday to Friday, 9:00am – 5:00pm, on: 01977 735865 option 2.

If you are under 16 years old and would like to contact the team, please speak to a parent, carer or professional (such as your GP or school) who will be able to support you with this.

Please note that a child or young person must be registered with a GP practice in Wakefield to access support from Wakefield CAMHS.

You can also download the guide to Wakefield CAMHS for more information. This includes information on what Wakefield CAMHS can help with, how we share information and what to do in an urgent or emergency situation.

Questions marked with a * must be completed, please.

Wakefield CAMHS e-referral form

Step 1 of 2 - Who is making the refererral

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Details of the person completing this form
Are you completing this form for yourself or on behalf of someone else?*
- For myself
- On behalf of someone else
Have you sought permission to complete this referral form on behalf of the young person?*
This is permission from the young person and/or parent carer to make this referral.

The service cannot accept a referral without permission being sought first.
Yes, I have permission to submit this form on behalf of the young person
Relationship to child or young person*
Are you a:
- Parent or carer
- Professional
Parental responsibility*
By ticking this box you confirm that you have parental responsibility for the young person
I have parental responsibility for the young person
Your name*
Prefix First Last
Your job title*
Professional person address*
Please use your work address.

Street address Address line 2 Town/city Postcode
Parent/carer address*
Please enter your address and not the young persons.

Street address Address line 2 Town/city Postcode
Your email address*
Enter Email Confirm Email

Child or young person details
Please try to answer each question as best as you can. If you are filling in this form on behalf of a child or young person, please read out and go through each question with them and record the answer in the relevant box.
Name*
First Last
Date of birth*

Day
Month
Year
NHS number (if known)
Ethnicity
Gender
Pregnancy or child under one
Are you (or if you are referring on behalf of someone else, the young person) pregnant or care for a child under the age of one?
- Yes
- No
Preferred spoken language
Address*
Street address Address line 2 Town/city Post Code
Phone*
After completing the form you will be first contacted by phone. This will be from a withheld number. If you are a parent, carer or professional completing the form on behalf of a child or young person, you must write your phone number and not that of the child or young person seeking help.
GP surgery*
Other GP surgery*
Please tell us your registered GP surgery
School or College
Name of School or College young person attends
Addtional support
Does the young person need additional support to be able to use or work with the service? E.g. translation services or interpreters and other accessible information.
About the child or young person
Mental Health*
Please describe the mental health difficulty that you (as a young person) are experiencing? If you are a parent, carer or professional completing this on behalf of a child or young person, please work with them to record their experiences in this section. Please include when the problems started, what’s happening now, how often it happens, and how it is impacting on family life, school and friends. Please also consider recent changes and significant life events.
Sleep patterns*
Please can you describe your (if self-referring) or the child or young person’s (if a parent, carer or professional referring) sleep patterns? Are there any of the following difficulties; struggling to fall to sleep or settle, sleeping too much, sleeping through the day, night time waking, early morning waking, night terrors/nightmares or others?
Life changes*
Has there been a significant life event recently may have led to the current mental health difficulties? This could be the loss of a family member or friend, trauma, witnessing or experiencing abuse including domestic violence.
Eating habits*
Are there any eating concerns (changes in eating behaviours e.g. food restriction or self-induced vomiting, preoccupation with food, weight or shape, excessive exercise)
Physical symptoms*
Are you or the young person experiencing any physical symptoms? (if yes, please provide details e.g. recent weight changes, dizziness / fainting) - open text box
Help and support already received*
Please share with us details of any help or support already received from a health care professional or service. This could be from school, Kooth or another counselling service. Please include details of what has been tried already, what worked and what didn’t work.
Different types of support*
CAMHS is able to offer different types of support. This could be therapy, education sessions, teaching coping strategies, or medication. Please tell us which type of support you think would help best. Please tell us which type of support would help you best.
Improvements*
What improvements would you like to see after receiving support from CAMHS?
Consent to share information with other third parties*
Do you consent, or have consent from the young person, to share the information you have submitted in this form with other third parties outside of CAMHS e.g. GP practice, school etc.? (Please note if consent if not given, CAMHS may contact you to discuss this referral in more detail)
- Yes
- No
Please read our privacy policy

Wakefield CAMHS aims to keep everything we are told confidential. There are times, however, when we cannot promise to do this. If we think that a child or someone else is at risk of harm or that they are in any danger, we must pass this information on to other professionals. We have a duty of care to keep children, young people and families safe.

By ticking the consent box, you are agreeing to share your information with the Wakefield CAMHS team who will be in touch within three working days.

Unless you stated otherwise the team would prefer to contact you by telephone to discuss your referral. Please note the caller number will not be displayed and will show up on your phone as a private number – so please make sure you answer this.
Consent*
‘I understand information on this form will be shared with Wakefield CAMHS'
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Page last updated on: 17^th February 2022

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