Please provide as much information as possible on this referral form, as it will help us to choose the most appropriate team member of The Bridge, for the initial assessment.



If you would like to refer your child or young adult to our services then please complete the following form and we will be in touch. All of the information you provide will be kept confidential. By completing this form you confirm that you have parental responsibility for the child or young adult you are referring.


Name:
Email address:
Phone number:
Relationship:
Patient name:
Patient birthdate:
Main concerns:

What do you want from our involvement?


Does the child or young person have any existing diagnoses?


Please select any health professionals that have been involved with the child or young person.

Mental Health Nursing (CAMHS)
Psychologist
Doctor
Paediatrician
Dietitian
Other
Don't know