Self-Referral Form

Name

Email

Address

Pronouns

Ethnicity

Contact number:

Please give details of relevant key workers Eg, Social Worker / Teacher / Youth Justice Worker

Key worker name:

Job title:

Organisation:

Contact number:

What schooling/education do you receive:

Are you receiving support from CAMHS?

What is the reason for the referral?

What are your biggest concerns? (please tick all that apply)

Harm to self Harm from others Anxiety/worry Depression/low mood Physical health/illness COVID-19 Bereavement Caring responsibilities Employability Offending behaviour Personal safety Family problems/home life Sexual Health Community involvement Discrimination Sexuality or gender issues Education support Domestic Abuse

What goal would you like to work towards?

What needs to happen to improve things for you? (please tick all that apply)

Community involvement Explore hobbies/interests Learn new coping strategies Learn independent living skills Healthier lifestyle habits Crisis planning Make plans for future Feel safer Better relationships at home Access support/services Make friends Other (describe below)