Self referral

Self Referral

The Child and Adolescent Mental Health Service in Somerset welcome self- referrals for any young person aged 16 or 17 years old, who may have concerns about their mental health.

The Single Point of Access team will discuss the referral with the young person and agree on the best way forward and ensure the young person receives the appropriate level of support.

Young people can self-refer by either completing the self-referral form or contacting the team on 03001245012. (Please note that the self-referral can only be completed by the young person).

CAMHS Self Referral

Name*
First Name Last Name
We need all of this information, without it, you cannot submit the form
Preferred Name
Date of Birth*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Phone number to be contacted on between 9am - 4.30pm*
Email address*
Your School/College/Work Place*
Do you have any difficulties in communicating?
E.g. deafness, anxiety on the phone, etc. If yes please state your difficulty and why you may find it difficult
Your GP Practice*
Reason for Self Referral*
We just need to understand a little bit more about what has been difficult. It would be helpful to know of any significant life events/changes that are affecting you e.g. parental separation, bereavement, how you are sleeping and eating, whether anything worries you and how long these difficulties have been going on for. No matter how much or little information you give we will still contact you.
Parents/Guardians/Next of Kin Name
First Last
This information is nice to know, so if you are happy for us to have this information, please complete it
Parents/Guardians/Next of Kin Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Parents/Guardians/Next of Kin Phone Number
What is their relationship to you?
Any other professionals, services or an adult who is supporting you that may be helpful for us to know about:
Name and details would be helpful here
Information Sharing with Parents/Carers*
- Yes
- No
I am happy for my information to be shared with my parents/carers. This will be further discussed when we make contact
Consent*
- I consent to the below
• You are aged 16 or 17. • You will be contacted from CAMHS via phone one working day after we receive your referral. • Your information will be kept securely on our computer system. Please note: If we have concerns about risk to life and are unable to contact you steps will have to be taken to ensure your safety.
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