Professional referral | CHUMS referral form for professionals

CHUMS referral form for professionals

You have now entered the referral form for professionals. To help us fully understand the problem that you are experiencing please answer all the questions as clearly and fully as you are able to. Before completing the information please ensure that you have the permission of the young person or their parent/carer to share this information with us.

TRAUMA Service referrals

If referring to the Trauma service, please include the following information: what specific event occurred and when/how long ago, what changes have been observed since the event?

CHUMS Direct Online is a privately paid service, separate from our commissioned services. It offers support for individuals who are not eligible for commissioned pathways or who require out-of-hours options. Please book your workshop or assessment first on https://chums-direct.uk/v2/.

If you are having difficulty with any of the questions or would rather speak to someone directly please call 01525 863924 during office hours (9 am to 5 pm).

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Details of person being referred

Service*

Where did you hear about CHUMS?*

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First Name*

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Last Name*

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Date of Birth (DD/MM/YYYY)*

Address Line 1*

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Address Line 2

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Address Line 3

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Town/City*

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County*

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Post Code*

Ethnicity*

Gender*

School*

GP Practice*

Name of Referrer*

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Job Title of Referrer*

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Address of Referrer*

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Contact Number of Referrer*

Referrer Email*

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Parent/Carer Name*

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Relationship to child*

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Parent/Carer Address*

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Parent/Carer Email Address*

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Parent/Carer Mobile Number*

We will contact you via SMS text message to provide therapy appointments and reminders. Do you agree for us to contact you in this way?*

Yes

Information about the difficulty*

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What is the persons understanding of their referral to chums.*

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Is the child known to social care or any other organisations*

If yes, who?

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Is consent given to contact these other organisations*

Risk

Are you aware of any risks? (eg behaviours that are a risk to themselves/others such as self-harm, suicidal ideation, substance use and information about if you believe them to be at risk from others)

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Where risks have been identified, how are these currently being managed?

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Any other relevant information?

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I would like to receive a confirmation of my self referral to the email address I specified above. Please check the spam folders within your email if you do not receive a confirmation in your inbox.

I accept terms and conditions. *

Please note that CHUMS is not an Emergency Service and is not able to respond to this form urgently. Therefore, if there are any immediate risks identified or emergency care required please seek immediate advice from your GP/A&E.

Contact Telephone: 01525 863924

Contact Email: info@chums.uk.com