Request for help from Cheshire CYPMHS

Request for help from Cheshire CYPMHS

• This form is for Children and Young People's Mental Health Services (CYPMHS) and can be used to make a referral for a young person (under the age of 18 years) who is registered with a GP in Cheshire. 
• For young people with a Wirral GP please refer through the Wirral page on MyMind 
• This form is not to be used for ADHD and Autism assessment referrals. Please direct ADHD and Autism assessment referrals to the appropriate team for the area the young person is based in. Further details can be found on the AAT page on MyMind 
• There is a consent section at the end of this form, if you are completing the referral and the young person/family are not present please ensure that they have provided consent. It may be helpful to complete the referral with the young person/family.
• A copy of the consent form can be found here 
• If you are a young person and would like a referral to 0-18 CYPMHS then you may need some support to complete this form from an adult you feel safe to discuss this with. This could be a parent/ carer, a family member, your G.P. or a teacher for example.
• By completing this form, you are giving your consent to share the information supplied with partner organisations if we believe it is appropriate to do so.

If you require a copy of the referral, once you submit this form you will be presented with a button to print responses. You can then choose how to print your copy such as pdf or paper.

Declaration

Details of the young person's GP

Referrer details

In this section, we will ask you some questions about yourself as the person submitting the referral.