CYPRMC Referral form

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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 and 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


Please Note: We only accept referrals for under 18 years of age
Section 2 - Referrer's Information
Section 3 - Service(s) required
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.
1st service required 2nd Service required 3rd Service required
 

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