CHILD & ADOLESCENT MENTAL HEALTH SERVICE – SOUTH	 	
REFERRAL FORM
Fax or email to Mental Health Services Helpline on 6173 0306 or mshelpline@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.
•	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.
REGISTRATION DETAILS	
Family name: <<Patient Demographics:Surname>>	Given names:  <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>	
Date of birth: <<Patient Demographics:DOB>>	Sex: <<Patient Demographics:Gender>>	
Address:<<Patient Demographics:Full Address>>	
Ph (home): <<Patient Demographics:Phone (Home)>>	Ph (work): <<Patient Demographics:Phone (Work)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	
Email: <<Patient Demographics:E-mail>>	Aboriginal or Torres Strait Islander: <<Patient Demographics:ATSI>>	
Language spoken: *****	Interpreter required: <<Does the patient require an interpreter?>>	
PARENT/ CARER/ GUARDIAN DETAILS	
Name: *****	Relationship to young person: <<Parent/guardian/carer relationship to patient:>>	
Address (if different to above): *****
	
Ph (home): *****	Ph (work): *****	Mobile: *****	
Email: *****	Aboriginal or Torres Strait Islander: <<Does the parent/guardian/carer identify as>>	
Language spoken: *****	Interpreter required: <<Parent/guardian/carer requires an interpreter>>	
Consents to the referral (legally required): <<Parent/guardian/carer consents to referral>>	Both parents aware of referral: <<Are both parents aware of this referral?>>	
REFERRER DETAILS	
Your name: <<Doctor:Name>>	Position/profession: *****	
Address: <<Practice:Address>>	
Phone: <<Practice:Phone>>	Fax: <<Practice:Fax>>	
Email: <<Practice:E-mail>>	
Period of involvement with young person: *****	Date of last contact: *****	
PRESENTING CONCERNS (please attach additional information if necessary)	
<<Clinical Details:History List>>	
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.): <<Is there a current legal order (e.g. family court)?>>
Please detail: *****	
Has there been a history of Child Safety Service involvement? <<Is there a history of child safety involvement?>>
If so, what were the reasons? *****	
Is there a family violence history? <<Is there a family violence history?>>
Are there current abuse patterns? <<Are there current patterns of abuse?>>
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 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 suicidal thoughts>>	Current suicidal intent: <<Is there current suicidal intent?>>	
Past suicide attempt(s): <<Has the patient made suicidal attempts 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