Community CYPS - Referral Form

Referral Criteria

We expect access to our service to be simple and easy. Our criteria for acceptance are: 

  • The child or young person must be within our age range 0-18 years
  • They must either be presenting with some degree of psychological distress or mental health difficulty. This includes children and young people in special circumstances (see page 2) of the referral leaflet whereby advice, consultation and/or support is being sought.  
  • They must have been seen by the referrer who will undertake an assessment of need prior to referral. This will help us to prioritise cases where necessary
  • They must have given informed consent to the referral being made.  

The service operates from a basis of ‘no bounce’. If a child or young person is not suitable for our service we will contact you to explain why and at the same time provide advice, help or support to access a service more appropriate to meet their needs. There is an expectation that a first level intervention musty have been attempted prior to referral and information on the outcome of this included in the referral.  

Anyone who would like to have a discussion about a case prior to referral can contact our helpline for advice, information or support.  

Date of referral Required
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Referrer details

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Address Required
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Has the Child / Young Person been seen by you as a referrer: Required

Referral will not be accepted if the Child / Young Person has not been seen by the referrer.

The information below is essential and must be completed.

Young person details

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Date of birth Required
Invalid date
Address Required
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GP address Required
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Consent for this referral

Has the young person given consent? Required
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Parent / Carer address if different from above:

Other Agencies Currently Involved, or with Significant Past Involvements

Address
Date of involvement if known
Invalid date
Address
Date of involvement if known
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Reason for referral

Please state the nature of the mental health difficulty and the impact this is having on the young person and family functioning, including symptoms, onset and duration. Please add any other relevant family history or information.   
 

What has been tried previously eg. services or interventions and what was the outcome?

NB: A referral will not be accepted unless this section is completed.

If you feel this referral is urgent, please contact our Duty Team for    
Discussion.  

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Do any of the following ally to the child / young person? Please tick any that apply: Required
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Identified risks

Please inform us of any known risks, either in relation to the young person being a risk to themselves or others; any risk to the young person from others (eg sexual exploitation, sexual abuse, physical abuse); or any risks that may potentially occur to staff whilst working with this young person or family:
 

Child protection plan Required

Thank you for completing this form.

If you wish to discuss this referral prior to sending it to the service please contact us on Telephone 0191 566 5500 and speak with a member of our team who will be happy to answer any queries you may have.

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