Self-referral

Step 1

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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:

Please Select An Option Parent/carerYoung person

*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

Please Select An Option YesNo

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

Please Select An Option Please choose an optionWhite BritishIrishWhite OtherCaribbeanAfricanBlack OtherIndianPakistaniBangladeshiAsian OtherWhite & Black CaribbeanWhite & Black AfricanWhite & AsianMixed OtherChineseOther

*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

Please Select An Option Abbey Medical Centre, BeestonAcorn Medical PracticeApple Tree Medical CentreAshfield HouseAshfield Medical CentreBalderton Primary Care CentreBelvior Medical GroupBramcote Surgery, BramcoteBrierley Park Medical CentreBull Farm Primary Care Resource CentreCandleby Lane, CotgraveCastle Healthcare PracticeChilwell Medows Surgery, ChilwellChurch House Surgery, RuddingtonChurch Street Medical Centre, EastwoodChurchside Medical PracticeClipstone Health CentreCollingham Medical CentreColwick Vale SurgeryCompton Acres Medical Centre, West BridgfordThe Cottage Surgery, LoughboroughCreswell SurgeryCrown House SurgeryCrown Medical Centre - Sherwood Medical PartnershipDaybrook Health CentreEast Bridgford Medical Centre, East BridgfordThe Embankment Primary Care Centre, West BridgfordFamily Medical Centre, Kirkby-in-AshfieldForest Medical Group, MansfieldForest Medical Practice, MansfieldFountain Medical Practice The Fountain Medical CentreThe Gamston Medical CentreHama Medical Centre, KimberleyHarwood Close SurgeryHarworth Medical CentreHealdswood Surgery, SkegbyThe Health Care Complex, Kirkby-in-AshfieldThe Health Centre, East LeakeHealth Centre, Kirkby-in-AshfieldThe Health Centre, Radcliffe-on-trentHickings Lane Medical Centre, StaplefordHighcroft Surgery, ArnoldHill View SurgeryJacksdale Medical Centre, JacksdaleJessop Medical PracticeKeyworth Health Centre, KeyworthKingfisher Family PracticeThe Kirkby Community Primary Care CentreLady Bay Surgery, West BridgfordLakeside SurgeryLarwood SurgeryThe Linden Medical Group, StaplefordLombard Medical CentreLowdham Health Centre, LowdhamLudlow Hill Surgery, West BridgfordMajor Oak Medical PracticeManor Surgery, BeestonMeden Medical ServicesThe Medical Centre, Long BenningtonThe Medical Centre, Sutton-in-AshfieldMiddleton Lodge PracticeMill View SurgeryMisterton SurgeryNewgate Medical GroupNewgate Street, BinghamNewthorpe Medical Centre, EastwoodNorth Leverton SurgeryOakenhall Medical PracticeOakleaf SurgeryThe Oaks Medical Centre, BeestonOakwood Surgery, MansfieldThe OM SurgeryOrchard Medical PracticeOrchard Surgery, KegworthPark House Medical Centre, CarltonParkview Surgery, EastwoodPeacock Health, CarltonThe Peacock PracticePlains View Surgery, MapperleyPleasley SurgeryRainworth Health CentreRavenshead SurgeryRetford Primary Care CentreRiverbank Medical ServicesRiverside Health CentreRoundwood SurgeryRuddington Medical CentreRyecroft Street Health Centre, StaplefordSandy Lane SurgerySaxon Cross Surgery, StaplefordSelston SurgerySkegby Family Medical CentreSoar Valley Surgery, South BonningtonSouthview Surgery, West BridgfordSouthwell Medical CentreSt Georges Medical PracticeSt Peters Medical PracticeStenhouse Medical CentreThe Surgery, BilsthorpeThe Surgery, BlidworthThe Surgery, Burton JoyceThe Surgery, CalvertonThe Surgery, Church Walk, EastwoodThe Surgery, FarnsfieldThe Surgery, GedlingThe Surgery, GiltbrookThe Surgery, GothamThe Surgery, Kirkby-in-AshfieldThe Surgery, NewarkSurgery, Regent Street, KimberleyThe Surgery, Sutton-on-TrentThe Surgery, West BridgfordTickhill and Colliery PracticesTorkard Hill Medical PraticeTrent Bridge Medical PracticeTrentside Medical Group, NetherfieldTuxford Medical CentreTuxford SurgeryUnderwood Surgery, UnderwoodUnity Surgery, MapperleyThe Valley Surgery, ChilwellVillage Surgery, Long LaneThe Village Surgery, PinxtonWarsop Primary Care CentreWest Bridgford Health CentreWest End Surgery, BeestonWest Oak Surgery, MapperleyWestwood Primary Care CentreWillowbrook Medical PracticeWoodlands Medical Practice

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