Central Lancashire CAMHS self-referral

This form is for Central Lancashire, West Lancashire, Fylde and Wyre and Morecambe Bay.

Please complete the self-referral form below. All information submitted on this form will be treated with strict confidentiality.

If you have a parent or other adult who can support you to complete the form, they can help you to fill it in or fill it in for you.

If you are unable to complete the form online, you can download a copy, complete and post it to: Lancashire Care Foundation Trust (LCFT), Referral and Appointment Centre, FD GF 34, Daisyfield Mill, Appleby Street, Blackburn, BB1 3BL or email to C&F.ReferralCentre@lancashirecare.nhs.uk

Please phone 01254 612600 if you have any queries - we are available between 9am and 5pm, Monday to Friday.

You can also contact the CAMHS services to see whether there are any opportunities for you to call in to drop in sessions that they may run.

Are you referring yourself? Required

Yes

No (complete the form for the person you are referring and add your details when requested)

If you know your NHS number please enter it here

Please tell us what you need support with and how you are feeling at present. In this section, please indicate how long you have been experiencing this difficulty and how it impacts you. Required

Prior to this referral, have you accessed help from other mental health support services? Required

Yes

If you answered yes, was it related to your current difficulty?

Yes

Full name Required

Preferred name

Gender

What are your preferred pronouns? Required

If you selected other, please let us know what pronouns you use

Date of birth Required

If you are under 16 please give the name of a parent or carer

Your home address, including postcode Required

Can we write to you at home? Required

Yes

If someone else answers, can we leave a message with them? Required

Yes

Home phone number

Your mobile number

Email address

What is the best time of day to contact you? Required

Can we leave a message? Required

Yes

If you selected yes, which of these message options is OK? Required

Voicemail

Text message

If you selected yes, who can we leave a message with?

What is the best way to contact you? Required

If you are a young person referring yourself, are you happy for us to contact your parents if we cannot get hold of you directly? Required

Yes

If you answered yes, please provide their full name and contact details:

Do you have any additional needs you want us to know about?

If you are at school or college which one do you attend?

If you know your GP or GP practice name please tell us what it is

Are you having suicidal thoughts? Required

Yes

Are you self-harming? Required

Yes

Do you feel at risk in any other way? Required

Yes

If you answered yes to the above question, please provide further information:

Are you being hurt or threatened? Required

Yes

Are you caring for anyone? Required

Yes

If you are referring someone else, what is your name?

If you are referring someone else, what is your relationship to this young person? (e.g. Youtherapy worker, parent, carer)

If you are referring someone else, what is your address?

If you are referring someone else, what is your phone number?

Is the young person aware this referral is being made on their behalf?

Yes

Central Lancashire CAMHS self-referral

This form is for Central Lancashire, West Lancashire, Fylde and Wyre and Morecambe Bay.

Central Lancashire self-referral

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