Self-referral

Step 1

Note: Questions marked by * are mandatory

*This is a mandatory field. Please tick here to consent to your information being used in this way.

Confirm

Welcome to the Nottinghamshire Child and Adolescent Mental Health Service (CAMHS) online referral form. This referral will be read between 8am-5pm Monday to Friday, and we will aim to respond within 72 hours. Please contact CAMHS Single Point of Access (SPA) on 0115 854 2299 if you want to discuss this referral, or support during the above hours. If you have immediate concerns about your safety or safety of the person you are referring, you can contact SPA on the number above on weekdays until 6pm. Outside of these hours, contact CAMHS Crisis Team on 0115 844 0560 Monday- Friday 6pm-10pm, weekends and bank holidays 10am-6pm. Please go to your local A&E outside of these hours. For support out of these hours, please contact ChildLine on 0800 1111 or Samaritans on 116 123. Information within this referral will remain confidential. If there is any information that raises concerns about your safety or the safety of others, this information may be shared. Two separate CAMHS services cover Nottinghamshire. If your GP is within the Nottingham City boundaries then please find information on how to refer to their services on http://www.bemhnottingham.co.uk or by calling 0115 876 4000.

*This is a mandatory field. Are you a:

*This is a mandatory field. Is the young person aware of this referral? In most cases it is important that the young person is aware of the referral

Details about the person being referred

*This is a mandatory field. First name

*This is a mandatory field. Last name

Family name if this is different

*This is a mandatory field. Gender

*This is a mandatory field. Date of birth

*This is a mandatory field. Ethnicity

*This is a mandatory field. Preferred language

*This is a mandatory field. Address

*This is a mandatory field. Postcode

*This is a mandatory field. What is your preferred contact number?

*This is a mandatory field. What is the best day/time to contact you (Monday - Friday, between 8am and 5pm)? If we can’t contact you via phone, we will try to contact you by e-mail or letter.

*This is a mandatory field. GP Practice

Question 18

* Spam Guard: What is the next number after 5? Write the number as a word.

You are here: Page 1 of 4

Self-referral

Accessibility links

Search the Nottinghamshire Healthcare NHS Foundation Trust website

Self-referral

Privacy statement

Feedback on our services

Footer address

Self-referral

Accessibility links

Search the Nottinghamshire Healthcare NHS Foundation Trust website

Self-referral

Privacy statement

Feedback on our services

Footer address

Login