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Youth-Mental Health Referral Form

Name *

Address *

Phone number *

Date of birth *

Age *

Gender *

Ethnicity *

GP/Medical Centre *

Parent/Guardian's name and contact details *

NOTE:If the young person is over 16 years old their parents/guardians do not need to be involved.

Yes

If the young person is under 16 years old, it is important that the parent or guardian is aware of the referral.

Yes

Referrer name and details *

CAMHS involvement in the past and/or current?

Yes

Where does the young person prefer to be seen? *

Medical Centre

School

PHO

Please provide appropriate contact information if young person does not wish parents to be involved.

Are you at risk to yourself *

Yes

Are you having suicidal thoughts/Plan? Please use the box below to provide further information

Please provide as much background information as possible including main reason for request outlined clearly.

Self-Referral Forms

Active Families
Breastfeeding Advocate Referral Form
GRx Self-Referral form
Nutrition Self Referral Form
Youth-Mental Health Referral Form

Your Health

COVID-19 continues to throw new challenges our way. This summer, we’re all feeling the impacts in some way – physically, emotionally, and financially. Whether you’re feeling all good/ ka pai, or a bit hōhā or overwhelmed, it’s normal and okay. We’ve got all sorts of tips to help you through and boost your mental wellbeing.

Bowel Screening Programme
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