Sussex FCAMHS

South East Forensic CAMHS Service

Highmore, Western Road, Hailsham, BN27 3DY

fcamhs@spft.nhs.uk

Telephone: 0300 304 0048

Please note, you will receive an email advising you of your FCAMHS referral ID once the referral has been submitted successfully.

If you have referred a young person to the service we will contact you regarding this within 5 working days. If you have immediate risk concerns regarding the young person that you are referring, please follow your current crisis pathway to ensure that the young person is receiving the support they require.

Consent

Person's Details

Person's Name: *

Date of Birth: Day*

Date of Birth: Month*

Date of Birth: Year*

NHS Number: *

Age at referral: *

Gender: *

Pronouns:

Ethnicity: *

Religion: *

Address: *

Telephone Number: *

Next of Kin / Carer Details

Next of Kin / Carer Name: *

Next of Kin / Carer Address: *

Next of Kin / Carer Telephone Number: *

GP Details

GP Name/Practice: *

GP Address: *

GP Telephone Number: *

GP Aware of the referral? *

Yes

Referrer Details

Referrer Name: *

Referrer Job Title: *

Referrer Agency: *

Referrer Address: *

Referrer Telephone Number: *

Referrer Email: *

Please confirm your email address:

YP / CYP Section

Other Agencies Involved

Person's Circumstances

Living arrangements at time of referral:*

Social Care Status:*

Education Status:*

Criminal Justice Status:*

Reasons for Referral

Terms & Conditions

Consent and Information Sharing: -

Please note, by submitting this referral, you are confirming that you have followed your local consent policies. This includes gaining the relevant consent for referring to our service, and the sharing of appropriate information across agencies involved.

I have read and agree with the above terms and conditions.*