Psychology referral form (children and young people)
Instructions:
1. Complete this form with as much information as you can
2. Please e-mail completed form to the psychology secretaries:
C&APsychology@uclh.nhs.uk
To be completed by either health care professional, young person or parent
Date
Name of young person:
Date of Birth:
Hospital Number:
Consultant name:
Name of person completing form:
Relationship to young person:
Contact number for family:
Please tell us who is in the family
Whose idea is the referral to psychology?
Who else is aware of the referral?
Has the young person or family had any previous contact with psychological services?
If yes please tell us when, where and who?
In what ways was this helpful or not helpful?
Please describe what would you be wanting from psychological services
Is there any additional information that you think would be helpful for us to know
about
Contact information for the psychology team
Secretary (Andra): telephone 020 3447 9086/7932 email: C&APsychology@uclh.nhs.uk