Patient details
Surname
* Required
First name
* Required
Date of birth
* Required
Age
* Required
NHS number
* Required
Gender
* Required
Ethnicity
* Required
Preferred pronouns
* Required
Religion
* Required
Address
* Required
Is it safe to contact:
* Required
Yes
No
Home phone number (include if parent/carer's)
Mobile phone number (include if parent/carer's)
E-mail address (include if parent/carer's)
GP Practice
* Required
Practice code
Registered GP
Interpreter required?
* Required
Yes
No
If yes, state language including signing
Name of person with a parental responsibility
Relationship to referred child
* Required
Any special circumstances e.g. Foster Carer, Special Guardianship:
Address of person with parental responsibility
* Required
Phone number of person with parental responsibility
* Required
E-mail address of person with parental responsibility
* Required
Consent to send letters by Text – Young Person
* Required
Yes
No
Phone number
* Required
Consent date
* Required
Consent to send letters by Text – Parent Carer
* Required
Yes
No
Name
* Required
Phone number
* Required
Consent date
* Required
School
* Required
Main contact at school
* Required
Is school attendance an issue?
* Required
Don't know
Yes
No
Disability:
* Required
Yes
No
If yes, provide details:
Neurodiversity (diagnosed or suspected):
* Required
Children's safeguarding
Is the child/young person “looked after” as defined in the Children’s Act 1989?
* Required
Yes
No
Is the child/young person adopted?
* Required
Yes
No
Are there safeguarding concerns about the child/young person or family?
* Required
Yes
No
If yes, provide details:
Does the child/young person have a Child in Need Plan (CIN)?
* Required
Don't know
Yes
No
Is the child/young person subject to a Child Protection Plan?
* Required
Don't know
Yes
No
Does the Young Person require support for the emotional impact of a trauma:
Domestic abuse
* Required** None Yes No
Details:
Sexual abuse
* Required** None Yes No
Details:
Physical abuse
* Required** None Yes No
Details:
Emotional abuse
* Required** None Yes No
Details:
Other (please specify):
Please detail if the perpetrator has been convicted or if there are ongoing investigations with police:
Please detail approximate time lapsed since the trauma:
OTHER SERVICES / PROFESSIONALS INVOLVED (also include services they have been referred to):
Name
Agency, and what service they are providing
Contact phone number
Name
Agency, and what service they are providing
Contact phone number
Name
Agency, and what service they are providing
Contact phone number
Any other services/professionals
Has an Early Help/ Family Help Assessment been completed?
* Required
Don't know
Yes
No
Further helpful information: e.g. early help referral done by school:
What help has been sought prior to this referral (if not already detailed above)
Does the parent or carer have any known literacy problems?
* Required
Yes
No
If yes, provide details:
Do the parents/guardians have parental responsibility?
* Required
Yes
No
Are the parents/guardians agreeable to the referral?
* Required
Yes
No
Is the child/young person aware of the referral?
* Required
Yes
No
Has the child/young person requested this support?
* Required
Yes
No
Referral details
Reason for the referral: What are the current difficulties? Duration of current difficulties? Impact on functioning? What are the young person’s strengths? What support is being requested for this young person?
* Required
What has the young person or family experienced that may be relevant to understanding the current difficulties?
* Required
Significant medical history
Active
Date
Problem
Associated text
Date ended
Any other information
Date
Problem
Associated text
Date ended
Any other information
Drug
Dosage
Quanitity
Last issued on
Any other information
Drug
Dosage
Quantity
Last issued on
Any other information
Is the Young person on Hormonal Contraception?
* Required
Yes
No
Type
If yes please specify whether mental health symptoms occurred before or after starting hormonal contraception?
*Note, although research is inconclusive, there is some evidence to suggest that hormonal contraception may impact mood. We would advise that this is considered prior to making a referral.
Allergies
Alcohol, nicotine or substance use (please detail)
Risk assessment
Are there any issues that place this young person or others at risk?
* Required
Yes
No
If yes, provide details including dates of incidents, nature of harm, frequency of incidents, triggers:
Can this person be worked with on a one-to-one basis? (e.g. absconding, damage to property, risk to professionals)
* Required** None Yes No
Agreement to referral
The information on this form will be used to assess the emotional and mental health needs of the referred child/young person. Sometimes we may be able to re-direct the referral to a more appropriate service if consent is obtained to share the information with other agencies.
Have the parents/guardians given consent to allow CAMHS to share information as specified above?
* Required
Yes
No
Have the parents/guardians given consent to allow CAMHS to contact the referrer and other involved agencies to discuss this referral further?
* Required
Yes
No
Referrer details
Referrer's name
* Required
Referrer's job title or relationship to the young person
* Required
Referrer's organisation and address
* Required
Telephone number
* Required
E-mail address
* Required
Signature
* Required
Check this box to add signature
Date
* Required
CEDS Referral Form Triage Prompt Questions
Does the young person present with a suspected eating disorder?
Give details:
What is the young person’s current weight and height? And do they have a history of weight loss? If so, please give details including the current rate of weight loss.
Give details
Is the young person currently restricting their food or fluid intake? If yes, please give details. If malnutrition or dehydration is suspected, please include details of any physical health symptoms.
Give details
Does the young person report binging (eating large volumes of food in a short space of time) episodes? If yes, please give details.
Give details
Does the young person report any compensatory behaviours to control or reduce their weight – these include vomiting, laxatives, excessive exercise, diet pills? If yes, please give details.
Give details
For any suspected eating disorder, an assessment of physical health risk is essential. Please consider when the young person last saw their GP and consider requesting an urgent appointment to check the following according to Junior MARSIPAN Guidelines: blood biochemistry (full FBC’s, U’s and E’s, Potassium, Magnesium, Phosphate, LFT’s), blood pressure standing and sitting, temperature, pulse rate, weight and height and attaching these results to the referral. Seeks guidance from CEDS clinicians if you are unsure.
