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

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

If the referral is for a neurodevelopmental concern, please refer using the form on our Neurodevelopmental Pathway page.

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

Please keep a copy of any information submitted through this form, in case you need to refer to it or resubmit it. You can also select to be emailed a copy of your submission (at the bottom of the form). You may need to check your 'junk' folder in your mailbox for this email message.

Please note: if you attach files and then get an 'error' message when you go to submit the form - for example, because you have not completed one of the mandatory questions - you may have to attach the files again.

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

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DOB Required
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Ethnicity

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Is an interpreter needed? Required
Is the child excluded from school or at risk of being permanently excluded or doesn't attend school for any other reason? Required

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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Any known allergies? Required
Have you completed an Early Help Assessment (EHA)? Required
Have you arranged a Multi-Agency Meeting? Required
Is the child known to have a statement/EHCP/GRIP? Required
Looked After Child? Required
Child On A Protection Plan? Required
Children In Need? Required
Is the child privately fostered? Required
Is the child adopted? Required
Is the child involved in any court proceedings? Required

Who has parental responsibility for the child/young person?

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Is the family known to any of the following? If so, please tick and give names & telephone numbers

Details of services and professionals involved

Further information/reports attached to this referral Required

Consent

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Date
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I'm a child or young person

I'm a Parent or Carer

I'm a Professional

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