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Tuesday 17 October 2017
Derbyshire Healthcare NHS Foundation Trust
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Derby City and South Derbyshire single point of access (SPOA) – Specialist Children's Services

This online referral form is for GPs and primary care professionals in health, education and local government to contact the SPOA team to request support for children and young people with emotional and behavioural problems in the Derby City and South Derbyshire area only.


CAMHS in north Derbyshire is provided by Chesterfield Royal Hospital NHS  Foundation Trust - see their website for further information. 

 

» Indicates required fields

Single Point of Access - multi agency referral form (emotional & behavioural problems)

Ethnicity:

Is an interpreter needed? »
Is the child excluded from school or at risk of being permanently excluded or doesn't attend school for any other reason?  »

Reason for referral:

In order to process this referral appropriately it would be a great help if you could specify the nature of the concern: 

    

Please indicate significant problems & needs by underlining or highlighting any of the following: 

    

Low mood; hearing voices; anxiety/phobias; deliberate self-harm; suicidal thoughts/threats; other emotional difficulties; eating/weight difficulties; behavioural problems; social & communication difficulties; hyperactivity; stress; poor concentration; post trauma symptoms; abuse; family breakdown; bereavement; attachment needs; peer bullying; physical/ learning disability; learning needs; parental mental health needs.; obsession and/ or compulsions with inherent fear;  vocal or motor tics.

Any known allergies? »
Have you completed an Early Help Assessment (EHA)? »

Have you arranged a Multi-Agency Meeting? »
Is the child known to have a statement/EHCP/GRIP? »
Looked After Child? »
Child On A Protection Plan? »
Children In Need?  »
Is the child privately fostered? »
Is the child adopted? »
Is the child involved in any court proceedings? »

Who has parental responsibility for the child/young person?

Is the family known to any of the following? If so, please tick and give names & telephone numbers:

Details of services and professionals involved:

Further information/reports attached to this referral: »

Consent

Consent discussed with child/family and agreed for referral
Consent agreed to share and gather information between services