Single point of access referral form

Derby City and South Derbyshire single point of access (SPOA) – Specialist Children's Services

This online referral form is for GPs and primary care professionals in health, education and local government to contact the SPOA team to request support for children and young people with emotional and behavioural problems in the Derby City and South Derbyshire area only.

CAMHS in north Derbyshire is provided by Chesterfield Royal Hospital NHS  Foundation Trust - see their website for further information. 

Single Point of Access - multi agency referral form (emotional & behavioural problems)

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Ethnicity

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Reason for referral:

Please indicate significant problems & needs by underlining or highlighting any of the following: 

Low mood; hearing voices; anxiety/phobias; deliberate self-harm; suicidal thoughts/threats; other emotional difficulties; eating/weight difficulties; behavioural problems; social & communication difficulties; hyperactivity; stress; poor concentration; post trauma symptoms; abuse; family breakdown; bereavement; attachment needs; peer bullying; physical/ learning disability; learning needs; parental mental health needs.; obsession and/ or compulsions with inherent fear;  vocal or motor tics.

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Who has parental responsibility for the child/young person?

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Details of services and professionals involved

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Consent

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