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 No If the young person is under 16 years old, it is important that the parent or guardian is aware of the referral. Yes No Referrer name and details * CAMHS involvement in the past and/or current? Yes No 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 No 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.