CYP RMC Referral Form

CYPRMC Referral form

Section 1 2 and 3

Note: Questions marked by * are mandatory

CYP RMC Referral Form
Children and Young People's Specialist Community Health Services
(for Northamptonshire Healthcare NHS Foundation Trust & Northampton General Hospital)
& Emotional Wellbeing and Mental Health Services
(for Northamptonshire Healthcare NHS Foundation Trust CAMHS and Youth Counselling)

Please complete this form, as fully as possible, with relevant information and details to support the referral to be clinically screened. This will ensure the needs of the child or young person to be met by the most appropriate service or services. If you are making a referral for Attention Deficit and Hyperactivity Disorder, Autism Spectrum Disorder, Emotional Wellbeing or Mental Health Services please ensure that if there is an Early Help Assessment (EHA) this is attached. If there is not an EHA, please complete the questions as fully as possible.

Section 1 - Key information about the Child/Young Person

*This is a mandatory field. Legal first name of child/young person

*This is a mandatory field. Legal surname name of child/young person

Middle name(s) of child/young person

Other name(s) child is known by

*This is a mandatory field. Male or Female

Male
Female

*This is a mandatory field. Date of Birth

Please Note: We only accept referrals for under 18 years of age

NHS No (if known), must be 10 digits

Section 2 - Referrer's Information

*This is a mandatory field. Name

*This is a mandatory field. Job Title/Role

*This is a mandatory field. Agency/Organisation

*This is a mandatory field. Address and postcode:

*This is a mandatory field. Contact Number

*This is a mandatory field. E-Mail Address

Section 3 - Service(s) required

click here and complete the 0-19 referral form">

Please indicate the service(s) you think are required to support the needs of the child/young person. These services are provided by a range of organisations including Northamptonshire Healthcare NHS Foundation Trust (NHFT), Northampton General Hospital (NGH) and services provided and commissioned by Northamptonshire County Council and Nene & Corby Clinical Commissioning Groups.
**Please note** For referrals to the 0-19 service (school nurses) please click here and complete the 0-19 referral form
1st service required	2nd Service required	3rd Service required

*This is a mandatory field. Date Form completed

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CYPRMC Referral form

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