Referral form

 

CHUMS Referral Criteria

Thank you for visiting the referral area of our website. Before you make a referral it is important to read our general criteria (below) as well as any specific criteria for the clinical service you are referring into. If you decide to make a referral please include as much information as you can with regards the presenting issue.

Referrals into our Emotional Wellbeing Service are reviewed weekly at the CHUMS/CAMHS single point of entry meeting (SPoE). Following this meeting you will receive a letter or email advising the most appropriate service to support the child/young person. This may not be CHUMS or CAMHS, in which case you will be given contact details of the relevant service.

The following referral criteria is used across all our clinical services:

  • The young person must be 17 years of age or younger
  • Where two people have parental responsibility but live in different homes, we recommend that both parties are aware of any referral being made. However, CHUMS will accept appropriate referrals from either parent.
  • There must not be any unresolved legal issues or issues being investigated by social care. Where there is an ongoing court case professionals and families should be advised that it is better to refer once the case is concluded
  • CHUMS does not mediate residency and contact arrangements. Parents should be advised to approach the family mediation service or discuss with a solicitor
  • CHUMS will not be involved in any legal issues in relation to parental separation. Court reports should be commissioned by solicitors from professionals who work on a private basis.

Is it safe?

Submitted referrals are not stored within the website environment or with any other third party. Referrals are transmitted via email directly from the website to a specific email address within CHUMS which is only accessible to authorised CHUMS personnel. Transmitted emails are encrypted using industry standard TLS (Transport Layer Security).

Child's details:

Child's first name (required)

Child's last name (required)

Address (required)

Town/village (required)

Postcode (required)

 

Date of birth (required)

Day:
Month
Year

 

Child's ethnicity (required)

Child's gender (required)

School (required)

Name of G.P (required)

G.P practice (required)

Can we contact this G.P
YesNo

 
Parent/Carer Information:

Parent/Carer name (required)

Relationship to child (required)

Address (required)

Town/village (required)

Postcode (required)

Contact number (required)

Email (required)

 
Parental Responsibility and Consent (required) :

I have parental responsibility for this child and give my consent to CHUMS to work with them.

Does anybody else have Parental Responsibility? If so who?

 

Presenting information:

Information about the difficulty (required)

What is the child's understanding of the referral to CHUMS? (required)

Is your child known to social care or any other organisations? (required)
YesNo

If yes, who?

 
Do you give consent for us to contact these other agencies?
YesNo

Risk:

Are you aware of any risks? (e.g. behaviours that mean they are a risk to themselves or others such as self-harm, suicidal ideation, drug/alcohol use, or violent behaviour, and information about whether you believe them to be at risk from others)

Where risks have been identified, how are these currently being managed?

Any other relevant information?

 

Child's details:

Child's first name (required)

Child's last name (required)

Address (required)

Town/village (required)

Postcode (required)

 

Date of birth (required)

Day:
Month
Year

 

Child's ethnicity (required)

Child's gender (required)

School (required)

Name of G.P (required)

G.P practice (required)

 

Parent/Carer information:

Parent/Carer name (required)

Relationship to child (required)

Address (required)

Postcode (required)

Contact number (required)

Email (required)

 

Does this family need an interpreter

YesNo

If yes, which language?

 

Presenting information:

Information about the difficulty (required)

What is the child's understanding of the referral to CHUMS? (required)

Is the child known to social care or any other organisations? (required)
YesNo

If yes, who?

Are you aware of any risks? (e.g. behaviours that mean they are a risk to themselves or others such as self-harm, suicidal ideation, drug/alcohol use, or violent behaviour, and information about whether you believe them to be at risk from others)

Where risks have been identified, how are these currently being managed?

Any other relevant information?

 

Referrer details:

Your name (required)

Organisation (required)

Address (required)

Job title (required)

Your email (required)

Contact number (required)

 

Are the family aware that you are making this referral (required)

If you would like a copy of this referral form emailed to you for your records, please tell us the address you wish for this to be sent to:

 

If you are young person and would like to refer yourself into CHUMS, please complete the information below and we'll give you a ring at a time that suits you best. If you are a parent or professional wishing to refer a young person please use the other forms.

Your Name (required)

Your Age (required)

Contact number (required)

When would be a good time for us to call you?

Please note that CHUMS is not an Emergency Service and is not able to respond to this form urgently. Therefore, if there are any immediate risks identified or emergency care required please seek immediate advice from your GP/A&E.

If you have any questions regarding the referral form, please call us on 01525 863924.