Information about the person you are referring to us:

To be filled out electronically

Consent to refer;	NHS No.	-	-
Before making the referral please make sure you have:
• Met with the child or young person	Please tick	☐
• Gained consent from the child or young person to refer	Please tick	☐
• The parent / guardian has given consent to the referral	Please tick	☐
• The parent / young person has consented for the referral to be . shared with other CAMHS partners if necessary	Please tick	☐
• Consent to store information on secure Seedlings database	Please tick	☐
Details of the child	Additional requirements
First Name	Language spoken	Language
Surname	Is an interpreter required?	Please tick	☐
DOB	Enter Date of Birth	Language required
Country of Origin	Disability?	Please tick	☐
How does the child describe their
Gender	Choose one please.
How does the child describe their
Sexuality	Choose one Please
Parental/Guardian contact details
Address	Tel no
Mobile no
Postcode	Email
Who has parental responsibility?
Parent / Carer’s name
Parent’s Address (if different from above)
Parent’s contact number
RISK ASSESSMENT Are you aware of any risk to PSS Seedlings staff during visits to the home, i.e. domestic violence, antisocial behaviour, pets? If yes, please give details
GP details
GP practice name
GP name
Surgery address
Phone no.
Referrer Details	Date Referred	Click here to enter a date.
Name
From (Agency, ect)
Job Title
Tel No
Mobile
Email
Family; (Please give all relevant family members)
Full Name	Age	Relationship to child	Currently live with child
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Presenting Issues;
☐	Anger	☐	Depression	☐	Grief / Loss	☐	Relationship
☐	Anxiety	☐	Disability	☐	Hearing Voices	☐	School
☐	Assault	☐	Domestic Abuse	☐	OCD	☐	Self Esteem
☐	Attempted Suicide	☐	Substance Misuse	☐	Parental Mental Health	☐	Self-injury
☐	Behaviour	☐	Eating Issues	☐	Parental Separation	☐	Sexual Abuse
☐	Bereavement	☐	Family	☐	Parental Substance Use	☐	Sexuality
☐	Bullying	☐	Gender Identity	☐	Rape	☐	Trauma
☐	Low Mood	☐	Other (please describe);
Reason for Referral
Please choose your main concern
Any additional information / other requirements:
Professionals Involved
Currently accessing
Historic access
What was the outcome
UK Status	Choose an item.	Other
Ethnicity	Choose an item.	Other
Religious Beliefs	Choose an item.	Other
Legal Status
Care of Parent	☐	Liverpool/Sefton/other	☐	Interim Care Order	☐
Care of Local Authority	☐	Section 20 Voluntary	☐	Care Order places at home	☐
Other Carer – give details	☐	Full Care Order	☐	Child Protection Plan	☐
Details
Educational information
School Name
Year Group	Contact No
Key School Contact
Role of Contact
NEET	☐	Is there a statement of educational needs?	☐	Child in Need	☐	EHCP	☐
EHAT open (CAF)	☐	EHAT number
Please send to Seedlings@PSS.org.uk