Young people - Online-referral - Combined Wellbeing

Getting the right help

If you are in mental health crisis or need urgent help

Call 111

Routine referrals Currently for under 18's only

If the young person is registered with a GP within Stoke-on-Trent or North Staffordshire, you can make a referral using the form below. If you need to contact the Crisis Care Centre please call 0800 0328 728

Areas covered by North Staffordshire Combined Healthcare

GPs covered by North Staffordshire Combined Healthcare

Register with a GP Surgery

Young people - Online referral form (ages 4 - 18)

We want to make sure that you receive the best help possible, as quickly as possible, from the best service for you. The referral form asks for lots of information about you in order to achieve this. If you can find somewhere quiet, where you won’t be interrupted, this will help.

Step 1 of 64

Please complete the form below to the best of your ability as it will help us find the right level of support for you.
Hidden
DEM_Form_Type_NR(Required)

Hidden
DEM_REFERRAL_REASON_NR(Required)

Hidden
Form Process Status(Required)
Hidden
DEM_LORENZO_REFERRALID_NR
Who is being referred?(Required)

I'm referring myself

I'm referring a young person
What is your relationship to the young person?(Required)
Hidden
GEN_REFERRAL_SOURCE_CODE_NR

Hidden
GEN_REFERRAL_SOURCE_DESC_NR

Hidden
GEN_REFERRING_ORG_NR

For future use when referral source and referring organisation are mapped.
I agree to information being shared between agencies.(Required)
North Staffordshire Combined Healthcare NHS Trust delivers a wide range of high quality healthcare services in partnership with many other organisations including the public, charities, voluntary, third party and private sector. To ensure we deliver the best care for our patients without the need to constantly repeat themselves we share only the minimum amount of information required for our partners to provide the continuity of care our patients expect. By continuing with this referral you consent to your information being stored and shared between our relevant partners as described above. All patient information is held securely, and access is controlled in accordance with the Data Protection Act 1998. North Staffordshire Combined Healthcare NHS Trust's privacy policy can be accessed here: https://combinedwellbeing.org.uk/data-privacy-gdpr/
I agree to information being shared between agencies.

Yes

No
Unfortunately, without your consent you can't proceed any further.

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GP (Doctor) details
Is the referred person registered with a GP in this area?(Required)

Yes

No
As the referred person is not registered with a GP in our area, we are unable to proceed with their online referral. Please call 0800 032 8728 or text on 07739 775202 stating that you would like support in relation to GP details to enable you to process the online referral
GP Practice(Required)
If you do not know the GP's details, or you cannot find the GP practice, then please select "NONE OF THE ABOVE"
If you are unsure of the referred person's GP, please call 0800 032 8728 or text 07739 775202 stating that you would like support in relation to GP details to enable you to process the online referral.
Hidden
GP_Is_In_Area_NR

Hidden
DEM_LORENZO_TEAM_NR(Required)

Team: SPA - Single Point of Access

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When you see the phrase "Referrer" we mean you as the person who is making this referral to CAMHS.
Your name(Required)
First Last
Referrer's address(Required)
Address line 1 Address line 2 (optional) City or Town County (optional) Postcode

Telephone (preferred)(Required)
e.g. 01234 567890
Other telephone
e.g. Mobile number
Email address(Required)
Enter Email Confirm Email

Please describe the services they have had or are having
Please confirm you have the agreement of the young person/their carer to make this referral.

Yes, I have consent

No, I don't have consent
If you do not have their consent you may fill in the form now, save it, and return to submit it when you have their consent.

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Young Person's details
In most circumstances you should have the consent of your parent/carer to make a referral. If you do not have their consent you may fill in the form now, save it, and return to submit it when you have their consent.
When you see the phrase "Young Person" we mean you as a young person referring yourself.
When you see the phrase "Young Person" we mean the young person or child that you are referring to CAMHS.
It is important to enter these details as accurately as possible, otherwise it might cause delays in offering help.
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Service User Identifier(Required)

Child or young persons name(Required)
Please enter in the child or young person's full name and NOT a shortened version of their name nor a nickname.
First Last
Hidden
Current Date(Required)
DD slash MM slash YYYY

This date is solely used to calculate the service user's age which is needed in conditional logic later in the form.
Date of birth(Required)
DD slash MM slash YYYY

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Age(Required)
This is the age of the young person. It will be calculated using the Date of Birth so that it can be used later on in the form to trigger events (e.g. messages or questions)
Hidden
Is_at_least_16_flag_Yes(Required)
This field is no longer required but it's kept here as a placeholder. Otherwise, back office processes would need to be changed.
Hidden
Is the Young Person aged at least 16 years?

Ethnicity
Gender(Required)

Male

Female
What best describes the Young Person’s gender?(Required)

Female (including trans female)

Male (including trans male)

Non-Binary

Other gender (the Young Person prefers to self-describe)

The Young Person prefers not to say
Please tell us more(Required)
Does the Young Person identify as trans, non-binary or gender diverse (i.e. gender identity is different to the gender assigned at birth)?(Required)

Yes

No

The Young Person prefers not to say
What are the Young Person’s preferred pronouns?(Required)

She / Her / Hers

He / Him / His

They / Them / Theirs

The Young Person prefers not to say

Other/The Young Person prefers to self-describe
Please tell us more(Required)
What Is the Young Person’s preferred title?(Required)

Miss

Mrs

Ms

Mx

Mr

Master

Other
Please tell us more(Required)
NHS Number

Young Person's Address(Required)
Address line 1 Address line 2 City or Town County Postcode

How long has the Young Person lived at this address?(Required)

less than 6 months

between 6 to 12 months

between 1 - 3 years

greater than 3 years

unknown
How many times have they moved in the last 12 months?(Required)
Please enter a number from 0 to 20.
Telephone (preferred)(Required)
e.g 01234 567890
Other telephone
e.g 01234 567890
Email address(Required)
Enter Email Confirm Email

Email address
Enter Email Confirm Email

Name of school/college/nursery(Required)
To find a school quickly please type a few letters in its name and the list will get shorter. If you can't find or don’t know the school name please select "NONE OF THE ABOVE"
Please enter in the school/college/nursery.
Hidden
Is_MHST_School

Hidden
Target_System_MHST_Team

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Does the Young Person have any of these special care arrangements? Please select any that apply.
Looked after Child

Not known

No

Yes
Child in Need plan

Not known

No

Yes
Care Order

Not known

No

Yes
Early Help

Not known

No

Yes
Do you give CAMHS permission to disclose the details of the family the Young Person lives with?(Required)

Yes

No
Please provide names and contact details of care workers
Name Role e.g. Social Worker Contact Details

Please provide details of any education healthcare plan(s)
Is there any additional information for us to consider?(Required)

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What are your concerns for the Young Person?(Required)

Please note: Sleep hygiene is an important part of wellbeing and therefore questions about sleep patterns may be asked.
Wants to hurt self
Difficulties with Sleep
Feeling stressed, anxious, worried
Feeling low, sad, depressed
Concerns about violence and aggression
Concerns about rituals
Worried about eating or weight
Worried about bullying
Continuous thoughts about a significant life event that has recently happened
Concerns about hearing or seeing things that others can't
Having difficulties managing a physical health diagnosis
Concerns around development which impacts on social skills, learning, attention and communication both in school and at home
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Number of concern checked
This field is used to identify how many concerns have been selected. This value is used later in the form to render recommendations in the confirmation message.
Hidden
DEMOS_Multi_Concerns_Selected(Required)
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DEMOS_Multi_Concerns_Flag(Required)
Hidden
RCADS Age Range flag
Hidden
RCADS Service key selections flag
Hidden
SR SDQ Age Range flag
Hidden
NonSR SDQ Age Range flag
Hidden
SDQ Service key selections flag

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Risk of Harm
How long has this been going on?(Required)

Less than 2 weeks

2-4 weeks

More than 4 weeks
Has the young person ever self-harmed?(Required)

Yes

No
When was the last time that self-harm occurred?(Required)
In what way did the young person self-harm?(Required)
Did the young person need medical attention?(Required)

Yes

No

Your answers suggest an immediate risk and we would encourage you to call the Crisis Care Team NOW

on 0800 032 8728 Option 1

Alternatively, call 111

This is available 24 hours a day, 7 days a week

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What was the purpose of the self-harm?(Required)
Does the young person ever have thoughts that life is not worth living?(Required)

Yes

No

Not known
How often does the young person have these thoughts?(Required)

Constantly

Sometimes

Very rarely

Your answers suggest an immediate risk and we would encourage you to call the Crisis Care Team NOW

on 0800 032 8728 Option 1

Alternatively, call 111

This is available 24 hours a day, 7 days a week

Has the young person thought how they would act on these thoughts?(Required)

Constantly

Sometimes

Not at all

Your answers suggest an immediate risk and we would encourage you to call the All Age Access Team NOW

on 0800 032 8728 Option 1

Or text on 07739 775202

This is available 24 hours a day, 7 days a week

Is there anything else you would like to tell us?

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Are there any difficulties with sleep?(Required)

Yes

No

Sometimes

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Sleep
How long has there been difficulties with sleep?(Required)

2-4 weeks

More than 4 weeks

Thanks for contacting us! We are unable to proceed with the online referral until there has been difficulties with sleep for at least 4 weeks. Please wait until then before submitting a referral. In the meantime, please have a look at the Combined Wellbeing Portal for more guidance and information

Any difficulties in getting to sleep?(Required)

Yes

No

Sometimes
Any difficulties staying asleep?(Required)

Yes

No

Sometimes
Early morning wakening?(Required)

Yes

No

Sometimes
Feeling tired in the morning and throughout periods of the day?(Required)

Yes

No

Sometimes
Difficulty in concentrating or remembering things?(Required)

Yes

No

Sometimes
More irritable than usual?(Required)

Yes

No

Sometimes
Duration of sleep? (hours)(Required)
Please enter a number from 0 to 24.
Any issues with talking, walking or movements during sleep or has this been mentioned by someone else?(Required)

Yes

No

Sometimes
Please tell us more(Required)
Has a GP been consulted?(Required)

Yes

No
What is the treatment plan?(Required)
Use of caffeine, energy drinks?(Required)

Yes

No

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Anxious or Depressed
What is causing concern for the Young Person at the moment? Select all that apply
low mood
feeling anxious
feeling compelled to do things
something else?
Please explain
When did this start?

In the last month

In the last 3 months

In the last 6 months

In the last year

More than a year ago
Has it been getting worse over time?

No, about the same

Yes, a bit worse

Yes, a lot worse
On a scale of 0 to 10 (0 being the lowest) how would you rate the Young Person's mood currently?
0 - worst 1 2 3 4 5 6 7 8 9 10 - best
Are there times of day when the Young Person's mood is worse? Select all that apply
In the morning
In the afternoon
In the evening
no particular time of day
Some other time

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How does this affect the Young Person's life?

Most of the time

Some of the time

Occasionally
Tell us how it affects the Young Person's family, school and friendships

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Eating Disorders
Has the Young Person lost weight recently?(Required)

Yes

No
How much weight has the Young Person lost over 4 weeks?(Required)
Young Person's height (in centimeters) ?(Required)
Please enter a number from 90 to 220.
Young Person's weight (in kgs)?(Required)
Please enter a number from 15 to 115.
Hidden
ED_BMI

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Are other people worried about the Young Person's eating?(Required)

Yes

No
Please tick reason(s) why.(Required)
because the Young Person only wants to eat 'healthy' foods
because the Young Person is not eating as much as he/she used to
because the Young Person is exercising a lot
because the Young Person is disappearing after meals
because family meal times are upsetting
because the Young Person is not eating things he/she used to enjoy
because the Young Person will only eat a very small range of foods
because the Young Person eats a very large amount of food in a short space of time
because the Young Person frequently vomits after eating
because of something else (please explain)
You said the Young Person will only eat a very small range of foods, what type of foods is this?(Required)
Please explain.(Required)
Does the Young Person regularly feel dizzy, short of breath, or have pains in the chest?(Required)

No, or hardly ever

Yes, about once a week

Yes, a few times a week

Yes, every day
Has the Young Person been to the GP (doctor) about eating or weight?(Required)

Yes

No
When did the Young Person see the GP and what was the outcome?(Required)

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Do you make yourself Sick because you feel uncomfortably full?(Required)

Yes

No
Do you worry you have lost control over how much you eat?(Required)

Yes

No
Have you recently lost more than 6kg in a 3 month period?(Required)

Yes

No
Do you believe yourself to be Fat when others say you are too thin?(Required)

Yes

No
Would you say food dominates your life?(Required)

Yes

No

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You said that you make yourself feel sick because you feel uncomfortably ill... how often do you make yourself sick (vomit)?(Required)
How often is the Young Person sick (vomiting)?(Required)
How long has this been going on?(Required)

It is important for the Young Person to see a doctor (GP) about dizziness, shortness of breath or pains in chest
Hidden
ED_DizzyFaint_Advice_Given

Yes
Advised to speak to GP as soon as possible about dizziness, shortness of breath or pains in chest
Thank you for telling us about your eating and weight.

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Concerns about rituals
How long has this been going on?

Less than 2 weeks

2-4 weeks

More than 4 weeks
Please tell us more(Required)
Does this impact on daily living (school, activities, hobbies)?(Required)

Never

Sometimes

Often

Always
Does this impact on family life?(Required)

Never

Sometimes

Often

Always
On a scale of 0-10 (0 being the lowest), what is the level of concern?(Required)
0 - Not at all concerned 1 2 3 4 5 6 7 8 9 10 - Very concerned

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RCADS (Self referral)
RCADS_Self_Q1 through RCADS_Self_Q5(Required)
Please select the word that shows how often each of these things happens to you. There are no right or wrong answers.
Never Sometimes Often Always
I worry about things
I feel sad or empty
When I have a problem, I get a funny feeling in my stomach
I worry when I think I have done poorly at something
I would feel afraid of being on my own at home

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RCADS_Self_Q6 through RCADS_Self_Q10(Required)
Never Sometimes Often Always
Nothing is much fun anymore
I feel scared when I have to take a test
I feel worried when I think someone is angry with me
I worry about being away from my parent
I am bothered by bad or silly thoughts or pictures in my mind

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RCADS_Self_Q11 through RCADS_Self_Q15(Required)
Never Sometimes Often Always
I have trouble sleeping
I worry that I will do badly at my school work
I worry that something awful will happen to someone in my family
I suddenly feel as if I can’t breathe when there is no reason for this
I have problems with my appetite

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RCADS_Self_Q16 through RCADS_Self_Q20(Required)
Never Sometimes Often Always
I have to keep checking that I have done things right (like the switch is off, or the door is locked)
I feel scared if I have to sleep on my own
I have trouble going to school in the mornings because I feel nervous or afraid
I have no energy for things
I worry I might look foolish

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RCADS_Self_Q21 through RCADS_Self_Q25(Required)
Never Sometimes Often Always
I am tired a lot
I worry that bad things will happen to me
I can’t seem to get bad or silly thoughts out of my head
When I have a problem, my heart beats really fast
I cannot think clearly

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RCADS_Self_Q26 through RCADS_Self_Q30(Required)
Never Sometimes Often Always
I suddenly start to tremble or shake when there is no reason for this
I worry that something bad will happen to me
When I have a problem, I feel shaky
I feel worthless
I worry about making mistakes

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RCADS_Self_Q31 through RCADS_Self_Q36(Required)
Never Sometimes Often Always
I have to think of special thoughts (like numbers or words) to stop bad things from happening
I worry what other people think of me
I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds)
All of a sudden I feel really scared for no reason at all
I worry about what is going to happen
I suddenly become dizzy or faint when there is no reason for this

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RCADS_Self_Q37 through RCADS_Self_Q42(Required)
Never Sometimes Often Always
I think about death
I feel afraid if I have to talk in front of my class
My heart suddenly starts to beat too quickly for no reason
I feel like I don’t want to move
I worry that I will suddenly get a scared feeling when there is nothing to be afraid of
I have to do some things over and over again (like washing my hands, cleaning or putting things in a certain order)

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RCADS_Self_Q36 through RCADS_Self_Q40(Required)
Never Sometimes Often Always
I feel afraid that I will make a fool of myself in front of people
I have to do some things in just the right way to stop bad things from happening
I worry when I go to bed at night
I would feel scared if I had to stay away from home overnight
I feel restless

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RCADS (Non-self referral)
RCADS_NonSelf_Q1 through RCADS_NonSelf_Q5(Required)
Please select the word that shows how often each of these things happens. Where you see 'my child' this means the young person you are referring. There are no right or wrong answers.
Never Sometimes Often Always
My child worries about things
My child feels sad or empty
When my child has a problem, he/she gets a funny feeling in his/her stomach
My child worries when he/she thinks he/she has done poorly at something
My child feels afraid of being alone at home

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RCADS_NonSelf_Q6 through RCADS_NonSelf_Q10(Required)
Never Sometimes Often Always
Nothing is much fun for my child anymore
My child feels scared when taking a test
My child worries when he/she thinks someone is angry with him/her
My child worries about being away from me
My child is bothered by bad or silly thoughts or pictures in his/her mind

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RCADS_NonSelf_Q11 through RCADS_NonSelf_Q15(Required)
Never Sometimes Often Always
My child has trouble sleeping
My child worries about doing badly at school work
My child worries that something awful will happen to someone in the family
My child suddenly feels as if he/she can’t breathe when there is no reason for this
My child has problems with his/her appetite

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RCADS_NonSelf_Q16 through RCADS_NonSelf_Q20(Required)
Never Sometimes Often Always
My child has to keep checking that he/she has done things right (like the switch is off, or the door is locked)
My child feels scared to sleep on his/her own
My child has trouble going to school in the mornings because of feeling nervous or afraid
My child has no energy for things
My child worries about looking foolish

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RCADS_NonSelf_Q21 through RCADS_NonSelf_Q25(Required)
Never Sometimes Often Always
My child is tired a lot
My child worries that bad things will happen to him/her
My child can’t seem to get bad or silly thoughts out of his/her head
When my child has a problem, his/her heart beats really fast
My child cannot think clearly

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RCADS_NonSelf_Q26 through RCADS_NonSelf_Q30(Required)
Never Sometimes Often Always
My child suddenly starts to tremble or shake when there is no reason for this
My child worries that something bad will happen to him/her
When my child has a problem, he/she feels shaky
My child feels worthless
My child worries about making mistakes

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RCADS_NonSelf_Q31 through RCADS_NonSelf_Q36(Required)
Never Sometimes Often Always
My child has to think of special thoughts (like numbers or words) to stop bad things from happening
My child worries what other people think of him/her
My child is afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds)
All of a sudden my child will feel really scared for no reason at all
My child worries about what is going to happen
My child suddenly becomes dizzy or faint when there is no reason for this

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RCADS_NonSelf_Q37 through RCADS_NonSelf_Q42(Required)
Never Sometimes Often Always
My child thinks about death
My child feels afraid if he/she have to talk in front of the class
My child’s heart suddenly starts to beat too quickly for no reason
My child feels like he/she doesn’t want to move
My child worries that he/she will suddenly get a scared feeling when there is nothing to be afraid of
My child has to do some things over and over again (like washing hands, cleaning, or putting things in a certain order)

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RCADS_NonSelf_Q43 through RCADS_NonSelf_Q47(Required)
Never Sometimes Often Always
My child feels afraid that he/she will make a fool of him/herself in front of people
My child has to do some things in just the right way to stop bad things from happening
My child worries when in bed at night
My child would feel scared if he/she had to stay away from home overnight
My child feels restless

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Concerns about violence and aggression
What are the concerns about violence and aggression?(Required)

The young person's behaviour

The behaviour of others towards the young person
How long has this been going on?(Required)

Less than 2 weeks

2-4 weeks

More than 4 weeks
How often has this been happening?(Required)

On one occasion only

Monthly

Weekly

Daily
Have any verbal threats been made?(Required)

Yes

No
Please tell us more(Required)
On a scale of 0-10 (0 being the lowest), how likely will the threats be acted on?(Required)
0 - Not at all likely 1 2 3 4 5 6 7 8 9 10 - Very likely
Has there been any actual violence or aggression?(Required)

Yes

No
Please tell us more(Required)
What are your concerns?(Required)
Does this impact on daily living (school, activities, hobbies)?(Required)

Never

Sometimes

Often

Always
Does this impact on family life?(Required)

Never

Sometimes

Often

Always
On a scale of 0-10 (0 being the lowest), what is the level of concern?(Required)
0 - Not at all concerned 1 2 3 4 5 6 7 8 9 10 - Very concerned

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Continuous thoughts about a significant life event that has recently happened
How long has this been going on?(Required)

Less than 2 weeks

More than 2 weeks
Please tell us more(Required)
Thanks for contacting us! We are unable to proceed with the online referral until there have been concerns for at least 2 weeks. Please wait until then before submitting a referral. In the meantime, please have a look at the Combined Wellbeing Portal for more guidance and information

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Bullying
Is the bullying happening now?(Required)

Yes

No
Please tell us more(Required)

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Concerns about hearing or seeing things that others can't
How long has this been going on?

Less than 2 weeks

2-4 weeks

More than 4 weeks
Please select all concerns that apply
Feeling of being watched by other people
Feeling that the TV or radio is giving messages
Having unusual beliefs for the first time
Odd manner of thinking or speech
Inappropriate moods
Odd behaviour or appearance
Close family history of psychosis together with increased stress or deterioration in functioning
Please tell us more
Please select all concerns that apply
Spending more time alone
Falling out more with family and/or friends
Family or friends are concerned
Experiencing changes in appetite
Experiencing changes in mood
Concentration reduced
Feeling increasingly restless or agitated
Feeling tense, nervous or anxious
Getting less pleasure from things usually enjoyed
None of the above
Please tell us more
Has there been a change in usual functioning i.e. going out or socialising less? Is attendance at work, school, college, university affected or have performance or grades reduced? Has there been an impact on relationships?
If any of the above or similar applies, then please answer yes

Yes

No

Not Known
Is there a close family member (parent, brother or sister) who has previously experienced or been supported for psychosis?

Yes

No

Not Known
Please tell us who (Select all that apply)
Mother
Father
Brother
Sister
Aunt
Uncle
Grandparent
Please select all concerns that apply
Feeling of being watched by other people
Hearing or seeing things that others can’t
None of the above
Please tell us more
Please select all concerns that apply
Feeling that the TV or radio is giving messages
Having unusual beliefs for the first time
Odd manner of thinking or speech
Inappropriate moods
Odd behaviour or appearance
None of the above
Please tell us more
Are there concerns about keeping safe?

Yes

No

Your answers suggest an immediate risk and we would encourage you to call the All Age Access Team NOW

on 0800 032 8728 Option 1

Or text on 07739 775202

This is available 24 hours a day, 7 days a week

Please tell us more

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Physical Health
What is the physical health diagnosis?(Required)
How long have they been experiencing these difficulties?

Less than 6 months

7 months to 2 years

More than 2 years
How often does the Young Person have to go to hospital?

Every week

Every month

At least once a year

Less than once a year
From 0 (worst) to 10 (best), how would you rate their experience of going to hospital?
10 - best 9 8 7 6 5 4 3 2 1 0 - worst
How much does the Young Person struggle with the physical health diagnosis on a day-to-day basis?

A little

It varies

A lot
Please tell us more about what the Young Person struggles with in relation to their condition. Select all that apply
anxiety
frustration
anger
mood changes
In what way does the Young Person show their anxiety or mood changes? Select all that apply
spending a lot of time on their own
becoming withdrawn / quiet
tries to harm themselves
often tearful
avoiding specific things
In what way does the Young Person show their anger or frustration? Select all that apply
often gets hurt by accident
tries to harm themselves
lashing out at other people (verbally)
lashing out at other people (physically)
breaking things
avoiding specific things
Would you say that the Young Person's physical health diagnosis is the primary reason for struggling in this way?

Yes, definitely

Mainly

Partly

Not much

Hardly

No
What aspects of the condition most affect the Young Person's mood and behaviour? Select all that apply
pain
difficulty walking / getting around
feeling different from friends and other people
looking different from friends and other people
being unable to take part in activites / sport
coming to terms with the condition
having to take treatments
What areas of the Young Person's life are most affected? Select all that apply
managing treatments
school
friendships
leisure activities
being bullied or being called names
sleep
eating
What types of medication/treatment does the Young Person need? Select all that apply
Injections
Pills
Complex hospital procedures
Additional care at home
Infusions
Physiotherapy or rehabilitation
When the Young Person has this treatment or medication how does it affect them? Select all that apply
anxiety
fear
pain
finding it difficult to follow a treatment plan
feeling sick
avoids treatment
How much does the Young Person's condition impact on daily life for the rest of the family?

A little

It varies

A lot
Please tell us how it impacts daily family life(Required)
What do you think the Young Person needs help with?(Required)
What do you think the Young Person’s family needs help with?(Required)

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Concerns around development which impacts on social skills, learning, attention and communication both in school and at home

Thanks for contacting us! We are unable to accept development concern self referrals from people aged under 14 years. Please talk to your parent/ carer or a health / education professional instead. In the meantime, please have a look at the Combined Wellbeing Portal for more guidance and information.

Thanks for contacting us! We are unable to accept development concern self referrals from people aged under 14 years. Please talk to your parent/ carer or a health / education professional instead. In the meantime, please have a look at the Combined Wellbeing Portal for more guidance and information.

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Concerns around development which impacts on social skills, learning, attention and communication both in school and at home
In which setting(s) does this concern apply? Select all that apply
Home
Education
Work
None of the above
At what age did you notice this concern?

0-4 years

5-8 years

8-11 years

12+ years
How do you communicate with others?

Fluent speech (able to talk in sentences)

Short phrases (2-3 words)

Other
Please tell us more(Required)
Do you have concerns about how you communicate with others?

Yes

No
Please select all that apply:
Using repetitive speech
Copying what others say
Lacking social conversation skills
None of the above
Please tell us more(Required)
Do you have concerns about any of the following? Select all that apply
Use of eye contact, facial expression and gesture
Ability to make and maintain a friendship
Response to emotions of others (e.g. offering comfort)
Lack of sharing enjoyment or interest (e.g. showing things, pointing things out)
None of the above
Please tell us more(Required)
Do you have unusual or significantly intense interests?

Yes

No
Please tell us more(Required)
Do you need to follow strict routines?

Yes

No
Please tell us more(Required)
Do you get distressed if you can’t?

Yes

No
Please tell us more(Required)
Do you use unusual behaviours which help to soothe you such as hand flapping, jumping, spinning?

Yes

No
Please tell us more(Required)
Do you find it distressing if these behaviours are interrupted?

Yes

No
Please tell us more(Required)
Do you find usual experiences such as sounds, textures, smell, taste or movement distressing?

Yes

No
Please tell us more(Required)

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Concerns around development which impacts on social skills, learning, attention and communication both in school and at home
In which setting(s) is the concern present? Select all that apply
Home
Education
Work
None of the above
At what age was the concern first apparent?

0-4 years

5-8 years

8-11 years

12+ years
Select the area of most concern:

Inattention, impulsivity and hyperactivity

Communication, social interaction, repetitive behaviour and restricted interested

Both
Hidden
DEVCON_Non_Self_Area_Most_Concern_Flag(Required)
Please describe level of speech

No words at all

Single words

Short phrases (2-3 words)

Fluent speech (able to talk in sentences)
Are there concerns about:
Repetitive speech
Copying speech of others
Lack of social chit chat
Lack of to and fro conversation
None of the above
Please tell us more(Required)
Are there concerns about playing with their toys?

Yes

No
Please tell us more(Required)
Were there concerns about playing with their toys when younger?

Yes

No
Please tell us more(Required)
Are there concerns about:
Use of eye contact, facial expression and gesture
Interest in and ability to play with other children
Response to emotions of others (e.g. offering comfort)
Lack of sharing enjoyment or interest (e.g. showing things, pointing things out)
None of the above
Please tell us more(Required)
Are there concerns about:
Use of eye contact, facial expression and gesture
Ability to make and maintain a friendship
Response to emotions of others (e.g. offering comfort)
Lack of sharing enjoyment or interest (e.g. showing things, pointing things out)
None of the above
Please tell us more(Required)
Are there concerns about:
Unusual or significantly intense interests
Needing to follow strict routines and distress if unable to
Hand or finger flapping or complex movements (e.g. jumping whilst flapping, unusual spinning that is hard to interrupt – not isolated rocking)
Unusual sensory seeking behaviours (e.g. licking, close examination, stroking items you would not expect)
Significant distress to everyday experiences (e.g. sounds, textures, smell, taste, movement)
None of the above
Please tell us more(Required)
Select all of the concerns that apply:
Often forgetting where belongings are
Forgetting what has been asked
Being able to listen to what others have to say
Doing work as quickly as possible, even if it’s not the best
Struggling with understanding work at school/college/work
Quickly losing interest in activities
Avoiding completing homework/tasks that need some thought/time to complete
Mind wandering when trying to do a task
None of the above
Hidden
DEVCON_Non_Self_Inattention_Concerns_Flag(Required)
Hidden
DEVCON_Non_Self_Inattention_Concerns_Decision(Required)
On a scale of 0-10, where 0 is the least, what is the impact on daily life?
0 - No impact 1 2 3 4 5 6 7 8 9 10 - Severe impact
Please tell us more(Required)
Select all of the concerns that apply:
Talking a lot
Often talking over others
Being able to listen to a conversation and waiting to answer
Being able to wait in turn to talk/when playing a game/waiting in a queue
Seeming to always be on the go
Struggling to sit still even when ought to be still and quiet
Being able to remember what is needed for school/college/work on a daily basis
Mind feels busy a lot of the time
None of the above
On a scale of 0-10, where 0 is the least, what is the impact on daily life?
0 - No impact 1 2 3 4 5 6 7 8 9 10 - Severe impact
Please tell us more(Required)

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Strengths and Difficulties Questionnaire (Self referral)
SDQ_Self_Q1 thru SDQ_Self_Q5(Required)
For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain or the item seems daft! Please give your answers on the basis of how things have been for you over the last six months.
Not True Somewhat True Certainly True
I try to be nice to other people. I care about their feelings
I am restless, I cannot stay still for long
I get a lot of headaches, stomach-aches or sickness
I usually share with others (food, games, pens etc.)
I get very angry and often lose my temper

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SDQ_Self_Q6 thru SDQ_Self_Q10(Required)
Not True Somewhat True Certainly True
I am usually on my own. I generally play alone or keep to myself
I usually do as I am told
I worry a lot
I am helpful if someone is hurt, upset or feeling ill
I am constantly fidgeting or squirming

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SDQ_Self_Q11 thru SDQ_Self_Q15(Required)
Not True Somewhat True Certainly True
I have one good friend or more
I fight a lot. I can make other people do what I want
I am often unhappy, down-hearted or tearful
Other people my age generally like me
I am easily distracted, I find it difficult to concentrate

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SDQ_Self_Q16 thru SDQ_Self_Q20(Required)
Not True Somewhat True Certainly True
I am nervous in new situations. I easily lose confidence
I am kind to younger children
I am often accused of lying or cheating
Other children or young people pick on me or bully me
I often volunteer to help others (parents, teachers, children)

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SDQ_Self_Q21 thru SDQ_Self_Q25(Required)
Not True Somewhat True Certainly True
I think before I do things
I take things that are not mine from home, school or elsewhere
I get on better with adults than with people my own age
I have many fears, I am easily scared
I finish the work I'm doing. My attention is good

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Overall, do you think that you have diff‌iculties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people?(Required)

No

Yes - minor difficulties

Yes - definite difficulties

Yes - severe difficulties
How long have these difficulties been present?(Required)

Less than a month

1-5 months

6-12 months

Over a year
Do the difficulties upset or distress you?(Required)

Not at all

Only a little

Quite a lot

A great deal
Do the diff‌iculties interfere with your everyday life in the following areas?(Required)
Not at all Only a little Quite a lot A great deal
HOME LIFE
FRIENDSHIPS
CLASSROOM LEARNING
LEISURE ACTIVITIES
Do the difficulties make it harder for those around you (family, friends, teachers, etc.)?(Required)

Not at all

Only a little

Quite a lot

A great deal

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Strengths and Difficulties Questionnaire (Non-self referral)
SDQ_NotSelf_Q1 thru SDQ_NotSelf_Q5(Required)
For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain or the item seems daft! Please give your answers on the basis of the Young Person's behaviour over the last six months or this school year.
Not True Somewhat True Certainly True
Considerate of other people's feelings
Restless, overactive, cannot stay still for long
Often complains of headaches, stomach-aches or sickness
Shares readily with other children (treats, toys, pencils etc.)
Often has temper tantrums or hot tempers

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SDQ_NotSelf_Q6 thru SDQ_NotSelf_Q10(Required)
Not True Somewhat True Certainly True
Rather solitary, tends to play alone
Generally obedient, usually does what adults request
Many worries, often seems worried
Helpful if someone is hurt, upset or feeling ill
Constantly fidgeting or squirming

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SDQ_NotSelf_Q11 thru SDQ_NotSelf_Q15(Required)
Not True Somewhat True Certainly True
Has at least one good friend
Often fights with other children or bullies them
Often unhappy, down-hearted or tearful
Generally liked by other children
Easily distracted, concentration wanders

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SDQ_NotSelf_Q16 thru SDQ_NotSelf_Q20(Required)
Not True Somewhat True Certainly True
Nervous or clingy in new situations, easily loses confidence
Kind to younger children
Often lies or cheats
Picked on or bullied by other children
Often volunteers to help others (parents, teachers, other children)

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SDQ_NotSelf_Q21 thru SDQ_NotSelf_Q25(Required)
Not True Somewhat True Certainly True
Thinks things out before acting
Steals from home, school or elsewhere
Gets on better with adults than with other children
Many fears, easily scared
Sees tasks through to the end, good attention span

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Overall, do you think that the Young Person has difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people?(Required)

No

Yes - minor difficulties

Yes - definite difficulties

Yes - severe difficulties
How long have these difficulties been present?(Required)

Less than a month

1-5 months

6-12 months

Over a year
Do the difficulties upset or distress the Young Person?(Required)

Not at all

Only a little

Quite a lot

A great deal
Do the diff‌iculties interfere with the Young Person's everyday life in the following areas?(Required)
Not at all Only a little Quite a lot A great deal
HOME LIFE
FRIENDSHIPS
CLASSROOM LEARNING
LEISURE ACTIVITIES
Do the difficulties put a burden on you or the Young Person's family as a whole?(Required)

Not at all

Only a little

Quite a lot

A great deal

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Family details
Parent or Carer Name(s)(Required)
First Name Last Name Contact number(s) Gender This person has parental responsibility? Lives with the Young Person? Relationship to Young Person

Any additional needs of parent (e.g. disability, literacy, mental health issues, interpreter, etc)
Any additional needs of Young Person (e.g. disability, literacy, interpreter etc)
Are the family / carers living in significant Financial Difficulty? If so, please tick which

Yes

No

Not known
Please tick the boxes that describe the family situation
The Young Person receives free school meals
The local authority provides assistance for the family's most basic needs

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Siblings (optional)
Click on the + (plus) sign to add a row for each sibling.
Please tell us about the young person's brothers/sisters
First name Last Name Date of birth Gender Lives with the Young Person? School/Nursery

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Agency (optional)
Click on the + (plus) sign to add a row for each agency or organisation that has helped the family.
For example: Social Care, Paediatrician (a specialist children's doctor), Hospital Consultant, Education (School Nurse), Triple P, Health Visitor, Youth Offending Service. Please tell us as much information as you can
Agency Details
Agency Past Involvement (with approximate dates) Current Involvement Contact Person and Telephone Number

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More about the Young Person's life
Does the Young Person have any learning disabilities?

Yes

No

Not known
Please tell us more
Is the Young Person a "Young Carer" (i.e. has to look after an Adult who cannot look after himself / herself)

Yes

No

Not known
Please tell us more
Has there been any contact with local police?

No

Yes, just the once

Yes, more than once

Not known
When?(Required)
About what?(Required)
What was the outcome of the police contact?(Required)
Youth Caution
Community Resolution
Court
Something else
No Further Action
Youth Conditional Caution
Referral Order
Youth Rehabilitation Order
Not Known
What was the outcome of the Court?(Required)

Absolute or Conditional Discharge

Community Order

Custody (Detention and Training Order)

Not known/Awaiting Court Date
Can you tell us more?
Please tick the boxes that describe the Young Person's attendance at school / education / employment / training
No problems
Attending part-time
Missing some days through refusing to attend or truancy
Rarely attends
At high risk of being excluded or dismissed
Excluded
Not in education, employment or training
Please tick the boxes that describe the Young Person's attainment at school / education / employment / training
No problems
At school, well below year level in at least one subject
In work, some problems (e.g. timekeeping or work rate, etc)
Failing key exams
Below year group in all subjects
In work, has received formal warnings from employer
Dropped out of education or employment
Has there been a change in behaviour?

Yes

No
How long has this been going on?(Required)

For less than a month

For the last 6 months

For 6-12 months

For more than a year
Please tell us more(Required)

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Does the Young Person use drugs?

Yes

No

Not known
How long has the Young Person been using drugs?(Required)

For less than a month

For the last 6 months

For 6-12 months

For more than a year
Which drugs does the Young Person use?(Required)
How often?(Required)

Once a month

2-4 times a month

2-3 times a week

More than 4 times a week

Not known
Does the Young Person drink alcohol?

Yes

No

Not known
How long has the Young Person been drinking alcohol?(Required)

For less than a month

For the last 6 months

For 6-12 months

For more than a year
Which alcohol does the Young Person drink?(Required)
How often does the Young Person have a drink containing alcohol?(Required)

Not known

Never

Monthly or less

2-4 times per month

2 to 3 times per week

4 times or more per week
How many units of alcohol does the Young Person drink on a typical day when they are drinking?(Required)

Not known

0 to 2

3 to 4

5 to 6

7 to 9

10 or more
How often has the Young Person had 6 or more units on a single occasion in the last year?(Required)

Not known

Never

Less than monthly

Monthly

Weekly

Daily or almost daily
How often has the Young Person had 8 or more units on a single occasion in the last year?(Required)

Not known

Never

Less than monthly

Monthly

Weekly

Daily or almost daily
How often during the last year has the Young Person found that they were not able to stop drinking once they had started?(Required)

Not known

Never

Less than monthly

Monthly

Weekly

Daily or almost daily
How often during the last year has the Young Person failed to do what was normally expected from them because of their drinking?(Required)

Not known

Never

Less than monthly

Monthly

Weekly

Daily or almost daily
How often during the last year has the Young Person needed an alcoholic drink in the morning to get themselves going after a heavy drinking session?(Required)

Not known

Never

Less than monthly

Monthly

Weekly

Daily or almost daily
How often during the last year has the Young Person had a feeling of guilt or remorse after drinking?(Required)

Not known

Never

Less than monthly

Monthly

Weekly

Daily or almost daily
How often during the last year has the Young Person been unable to remember what happened the night before because they had been drinking?(Required)

Not known

Never

Less than monthly

Monthly

Weekly

Daily or almost daily
Has the Young Person or somebody else been injured as a result of the Young Person's drinking?(Required)

Not known

No

Yes, but not in the last year

Yes, during the last year
Has a relative or friend, doctor or other health worker been concerned about the Young Person's drinking or suggested that they cut down?(Required)

Not known

No

Yes, but not in the last year

Yes, during the last year
Does the Young Person want to reduce or stop drinking?(Required)

Yes

No

Not known

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Does the Young Person have concerns about relationships?

Yes

No

Not known
How long has this been going on?(Required)

For less than a month

For the last 6 months

For 6-12 months

For more than a year
Please tell us more(Required)
Has the Young Person been bereaved by the loss of a loved one including pets?

Yes

No

Not known
When was this bereavement?(Required)

Less than a month ago

Within the last 6 months

6-12 months ago

More than a year ago
Please give more information you think is relevant to this e.g. was it a sudden loss, what was the relationship to the loved one etc(Required)
Does the Young Person have concerns about sexuality?

Yes

No

Not known

Prefer not to say
How long have there been concerns?(Required)

For less than a month

For the last 6 months

For 6-12 months

For more than a year
Please tell us more(Required)
Does the Young Person have concerns about gender identity?

Yes

No

Not known

Prefer not to say
How long have there been concerns?(Required)

For less than a month

For the last 6 months

For 6-12 months

For more than a year
Please tell us more(Required)
Has the Young Person ever been pregnant?

Yes

No

Not known

Prefer not to say
When was this?(Required)

Less than a month ago

Within the last 6 months

6-12 months ago

More than a year ago
Please tell us more(Required)
Has the Young Person ever fathered a child?

Yes

No

Not known

Prefer not to say
When was this?(Required)

Less than a month ago

Within the last 6 months

6-12 months ago

More than a year ago
Please tell us more(Required)

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Has the Young Person ever had a sexually transmitted disease (STD)/sexually transmitted infection (STI)?

Yes

No

Not known

Prefer not to say
When was this?(Required)

Less than a month ago

Within the last 6 months

6-12 months ago

More than a year ago
Please tell us more(Required)
Has the Young Person ever been a victim of domestic abuse?

Yes

No

Not known
When was this?(Required)

Less than a month ago

Within the last 6 months

6-12 months ago

More than a year ago
Please tell us more(Required)
Has the Young Person ever witnessed domestic abuse?

Yes

No

Not known
When was this?(Required)

Less than a month ago

Within the last 6 months

6-12 months ago

More than a year ago
Please tell us more(Required)
Could the Young Person be at risk of exploitation?

Yes

No

Not known
When was this?(Required)

Less than a month ago

Within the last 6 months

6-12 months ago

More than a year ago
Please tell us more(Required)
Is the Young Person a refugee or asylum seeker?

Yes

No

Not known
Please tell us more(Required)

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Please attach any additional documents that you believe may be helpful (e.g. Care Order; Child Protection Plan; Education & Health Care (EHC) Plan; previous assessments). Up to 5 documents allowed in these formats: .doc, .docx, .pdf, .jpeg, .jpg, .png.

Drop files here or

Accepted file types: doc, docx, pdf, jpeg, jpg, png, Max. file size: 10 MB, Max. files: 5.

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Consent Section
The information from this form will be discussed within a multi-agency professional team to assess the appropriate course of action. We will contact you to advise you of the outcome. You may be contacted for more information if required. This information will be recorded on North Staffordshire Combined Healthcare's database.
Have you discussed this referral with your parents/carers?(Required)

Yes

No
You should discuss this referral with your parents/carers if at all possible before you submit it
What do you want to do?(Required)

I will discuss this with my parents/carers then complete the referral

I do not feel comfortable discussing this with my parents/carers and I want to make the referral anyway
I have discussed CAMHS services with the young person who agrees to me making this referral

Yes

No
You must discuss this referral with the young person before you can submit it.
I have discussed CAMHS services with the young person's parents/carers who agree to me making this referral(Required)

Yes

No
You should discuss this referral with the young person's parents/carers if at all possible before you submit it
What do you want to do?(Required)

I will discuss this with the parents/carers then complete the referral

I am concerned for the young person's safety if I discuss this referral with the parents/carers, and I want to make the referral anyway
I consent to the above referral and any assessments that may be required.(Required)

Yes

No
Without your consent the referral cannot be submitted
Do you consent to receiving messages from us via text?(Required)

Yes

No
Do you consent to us leaving voicemail on landline?(Required)

Yes

No
Do you consent to us leaving voicemail on mobile?(Required)

Yes

No
Do you consent to us using your referral for research purposes?(Required)

Yes

No
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CONSENT_Comms_Via_Text_Answered?(Required)
The value is set to 1 if this consent question has been answered.
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CONSENT_Comms_Via_Voicemail_Landline_Answered?(Required)
The value is set to 1 if this consent question has been answered.
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CONSENT_Comms_Via_Voicemail_Mobile_Answered?(Required)
The value is set to 1 if this consent question has been answered.
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CONSENT_Use_for_Research_Purposes_Answered?(Required)
The value is set to 1 if this consent question has been answered.
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CONSENT_Contact_Use_Answered_flag(Required)
The value is set to 1 if this consent question has been answered.
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REFERRAL_PRIORITY_NR
This section control the setting of the referral priority field.
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REFERRAL_PRIORITY_NR

Hidden
Single_Concern_Flag(Required)

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Single_Concern_Nbr_Flag
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SUBMIT_SELF_REF_PLUS_TALK_ADULT_NBR_Flag(Required)
Hidden
SUBMIT_SELF_REF_PLUS_TALK_ADULT_NR_DECISION(Required)
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SUBMIT_REF_ANGER_REF_TYPE_FAMILY_NBR_Flag(Required)

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SUBMIT_REF_ANGER_REF_TYPE_NONFAMILY_NBR_Flag(Required)

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SUBMIT_REF_ANGER_REF_TYPE_FAMILY_NR_DECISION(Required)
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SUBMIT_SELF_REF_NBR_Flag(Required)

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SUBMIT_SELF_REF_NR_DECISION(Required)
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SUBMIT_REF_NBR_Flag(Required)

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SUBMIT_REF_NR_DECISION(Required)
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Submitted Date(Required)
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This is the date when the form is ready for submission.
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If you are in mental health crisis or need urgent help

Call 111

Routine referrals Currently for under 18's only

Step 1 of 64

GP (Doctor) details

Young Person's details

Risk of Harm

Sleep

Anxious or Depressed

Eating Disorders

Concerns about rituals

RCADS (Self referral)

RCADS (Non-self referral)

Concerns about violence and aggression

Continuous thoughts about a significant life event that has recently happened

Bullying

Concerns about hearing or seeing things that others can't

Physical Health

Concerns around development which impacts on social skills, learning, attention and communication both in school and at home

Concerns around development which impacts on social skills, learning, attention and communication both in school and at home

Concerns around development which impacts on social skills, learning, attention and communication both in school and at home

Strengths and Difficulties Questionnaire (Self referral)

Strengths and Difficulties Questionnaire (Non-self referral)

Family details

Siblings (optional)

Agency (optional)

More about the Young Person's life

Consent Section

REFERRAL_PRIORITY_NR

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We hope you have found this site useful.

If you have a few minutes, please tell us about your visit.