Request for help (Wirral CAMHS)

If you or the young person is at immediate risk, please call the 24/7 urgent mental health line on 0800 145 6485.

By completing this form you are giving your consent to share this information with partner organisations if we believe it is appropriate to do so*

Request for help (Wirral CAMHS)

Young person's details

Name of young person *

Date of Birth *

If you answered Other to the previous question, please specify using full terminology

NHS Number Please enter the young person's NHS number. This can usually be found on any correspondence from the hospital

Name of parent/carer *

Name of person with parental responsibility (if different from above)

Young person's home address *

Main contact number of parent/carer or young person (if over 16) *

Email address of parent/carer or young person (if over 16) *

Details of person requesting help/advice

Name of person requesting help/advice *

Address of person requesting help/advice *

Phone number of person requesting help/advice *

Email of person requesting help/advice *

School/College

Name of school/college *

If you answered yes to the above, please provide further information

Details of GP

Name of GP (if known)

* Name of surgery *

Other Details

Has the young person already received support from another organisation? If yes, please give details *

If there is concern about the person’s weight or of a possible eating disorder? If yes, please give their height and weight *

Further information - please provide as much detail as possible

Have there been any changes to the young person's sleep pattern? * e.g. have they been sleeping too much or too little?

Have there been any changes to the young person's appetite? * e.g. is it smaller, larger or has it altered recently? If they are displaying eating concerns are they restricting the amount they eat, when and what are they eating, what is their current weight and height? Are they using laxatives or being sick after meals? Has their exercise increased?

Have there been any changes to the young person's mood? * It might help to use a rating scale of 0 to 10, (0 unhappy 10 happy). Is this a new presentation? Do they seem more anxious? When and with whom?

Has the young person displayed any signs of self-harm? * If so, what type, when does this happen, how often, is treatment ever required etc.

Please provide the details of any significant others e.g family members or other agencies involved (Social Care/ YOS etc) involved * Please provide as much detail as possible e.g. names/date of birth/relationship to young person

Has the young person expressed any suicidal thoughts, worries or behaviours? * If yes, explore with your young person when these happen and what they think they might plan to do?

How is school or college going? * Is the young person falling behind, have school raised concerns or offered support?

Has the young person withdrawn from usual social activities? *

Have there been any big events in the young person’s life? Anything that might have upset or frightened them? * If yes, what and when was this?

Please include anything else you think might help us understand the young person’s presentation; unusual behaviours, new habits, seeing or hearing sounds, voices or figures etc. *

Significant others

Please list any family members or other agencies involved in the young person’s life * Please include name/age/relationship to young person

Other relevant information

Please give any other details that you think might be relevant This could include some of the following (this is not an exclusive list): family separation, mental health difficulties of the parent / carer, drug or alcohol use by parent / carer or young person, relationship difficulties, physical health problems, witnessed or experienced domestic violence,experienced physical, emotional or sexual abuse, questioning gender identity etc.