CHILD & ADOLESCENT MENTAL HEALTH SERVICE – SOUTH	 	
REFERRAL FORM
Fax or email to Mental Health Services Helpline on 6173 0306 or mhshelpline@ths.tas.gov.au
<Form type>
BEFORE COMPLETING THE FORM PLEASE READ THIS SECTION CAREFULLY
<This form must be completed by a Primary or Secondary Health Care Provider, who has personally assessed the young person. We do not accept referrals made directly or indirectly by parents or carers.> This form must be completed by a Primary or Secondary Health Care Provider, who has personally assessed the young person. We do not accept referrals made directly or indirectly by parents or carers.
<Referrers are expected to maintain a case management responsibility for the young person. The referral to CAMHS should be considered only one component of the young person’s care plan managed by the referrer.> Referrers are expected to maintain a case management responsibility for the young person. The referral to CAMHS should be considered only one component of the young person's care plan managed by the referrer.
<Please complete all sections of this form legibly. Incomplete or illegible forms will be returned to the referrer for completion, which will delay processing by the CAMHS intake team.> Please complete all sections of this form legibly. Incomplete or illegible forms will be returned to the referrer for completion, which will delay processing by the CAMHS intake team. 
REGISTRATION DETAILS	
Family name: <PtSurname>	Given names: <PtFirstName> <PtMidName>	
Date of birth: <PtDoB>	Sex: <PtSex>	
Address:
<PtAddress>	
Ph (home): <PtPhoneH>	Ph (work): <PtPhoneWk>	Mobile: <PtPhoneMob>	
Email: <PtEmail>	Aboriginal or Torres Strait Islander: <Does the patient identify as Aboriginal or Torres Strait Islander?>	
Language spoken: *****	Interpreter required: <Does the patient require an interpreter?>	
PARENT/ CARER/ GUARDIAN DETAILS	
Name: *****	Relationship to young person: <Parent/guardian/carer details - relationship to young person>	
Address (if different to above): *****
	
Ph (home): *****	Ph (work): *****	Mobile: *****	
Email: *****	Aboriginal or Torres Strait Islander: <Does the patient's parent/guardian/carer  identify as Aboriginal or Torres Strait Islander?>	
Language spoken:	Interpreter required: <Does the patient's parent/guardian/carer require an interpreter?>	
Consents to the referral (legally required): <Does the patient's parent/guardian/carer consent to the referral? (legally required)>	Both parents aware of referral: <Are both parents aware of the referral?>	
REFERRER DETAILS	
Your name: <RefName>	Position/profession: *****	
Address: <UsrAddress>	
Phone: <UsrPhone>	Fax: <UsrFax>	
Email: <PracEmail>	
Period of involvement with young person: *****	Date of last contact: *****	
PRESENTING CONCERNS (please attach additional information if necessary)	
<PMHActive>	
FAMILY & PSYCHOSOCIAL BACKGROUND	
Others in the household & family: *****
	
School & grade: *****	School support service(s) involved (e.g., School Social Worker/Psychologist/Teacher’s Aide): *****
	
Any legal orders (Family Court, Child Safety etc.): <Are there any legal orders (family court, child safety etc) related to this patient?>
Please detail: *****	
Has there been a history of Child Safety Service involvement? <Has there been a history of Child Safety Service involvement with this patient?>
If so, what were the reasons? *****	
Is there a family violence history and/or current abuse patterns? <Is there a family violence history and/or current abuse patterns?>
Please detail: *****	
Is there a history of substance use? <Is there a history of substance abuse?>	
Are there any mental health issues in the family? <Are there any mental health issues in the family?>	
ASSESSMENTS & TREATMENTS ALREADY UNDERTAKEN	
Has the child seen a paediatrician? <Has the child seen a paediatrician?>
Dr: *****	
Agencies/professionals currently involved:	Name: *****

Contact details: *****

q Aware of referral	Name: *****

Contact details: *****
 
q Aware of referral	Name: *****

Contact details: *****

q Aware of referral	
Medical investigations/ current treatments:	Details: *****
	
Educational/psychometric assessment:	Details: *****
	
Speech/language assessment:	Details: *****
	
Occupational therapy assessment:	Details: *****
	
Others (specify):	Details: *****
	
SUICIDE/ SELF-HARM RISK ASSESSMENT	
Suicidal thoughts: <How often does the patient suffer from suicidal thoughts?>	Current suicidal intent: <Does the patient present with (current) suicidal intent?>	
Past suicide attempt(s): <Has this patient made attempts at suicide in the past?>
If yes, date of last suicide attempt: *****	Self-harm: <How often does the patient engage in self-harm?>	
Other risk factors (e.g., substances, homelessness, history of abuse): *****	
Social supports & other protective factors: *****	
Safety plan in place: <Is there a safety plan in place?> 
If yes, please attach a copy. 
Other details: *****	
SIGNATURE OF REFERRER	
Signed:
	Date: 	

When complete, please forward this Referral Form and all supporting documentation to the Mental Health Services Helpline: Phone 1800 332 388, Facsimile (03) 6173 0306, Email  mhshelpline@ths.tas.gov.au
Secondary Consultation Requests only:  
Please refer directly to CAMHS Intake by faxing on 6228 0090 or emailing clare.house@ths.tas.gov.au