CHALLENGING BEHAVIOUR PSYCHOLOGY SERVICE
A service for children and young people who have a global learning disability and/or an autistic spectrum
disorder who present with significant challenging behaviour in the home environment
REFERRAL FORM
PLEASE COMPLETE THIS FORM IN FULL IN CONJUNCTION WITH THE REFERRAL CRITERIA.
INCOMPLETE REFERRALS WILL BE RETURNED RESULTING IN A DELAY TO THE REFERRAL
PROCESS
Name of Child: _________________
Gender: __________________________
Date of Birth: __________________
N.H.S No: _________________________
Address: ______________________
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Tel: ______________________________
GP (name, address & telephone no):
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School (name, address & telephone no):
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Mobile: ___________________________
Names of those who hold Parental Responsibility? ____________________________
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Please provide parental contact details if different from the child/young person:
Referred by:
Date of Referral: ___________________
(Please state your name and job title)
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Signature: _________________________
Address:
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Tel: ______________________________
Consent to Referral
Have you discussed this referral with the family/young person?
Is the family/young person willing to attend the CBPS?
Does the family/young person consent to the CBPS contacting the
professionals involved prior to meeting us if appropriate?
CBPS Referral Form Version 4, January 2012
Yes
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No
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Please detail your involvement with the child/young person and in what capacity
you will continue to be involved.
If you are a CAMHS referrer please indicate if you are requesting joint assessment work or
CAMHS are discharging.
Please provide current evidence of whether the child/young person has a global
learning disability and/or an autistic spectrum disorder (as defined by the CBPS
eligibility criteria).
Please describe the child/young person’s challenging behaviour and include details
regarding the intensity, frequency, duration and impact of the behaviour.
Please consider how the behaviour presents at home, school and other settings.
Please describe how the behaviour is managed in the above settings:
Please describe the factors that influence the behaviour:
What is the child/young person’s view of the situation:
Please describe any recent life events the child/young person has experienced:
CBPS Referral Form Version 4, January 2012
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Please provide any further details you believe to be pertinent to the referral:
Professionals previously involved
Please provide details of the community interventions that have previously been undertaken in relation to the
behaviour (e.g. Autism Advisory Service, Behaviour Support Team, ADD-vance, parenting course) and the
dates of this input:
Professionals currently involved (Please add names and telephone numbers)
CAMHS
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Community Paediatrician
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Occupational Therapist
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Speech & Language Therapist
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Physiotherapist
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Health Visitor
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SENCO
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Educational Psychologist
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School Nurse
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BST worker
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Harper House
_______________________
Social Worker
_______________________
Autism Advisory Service
_______________________
Other
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Please specify any Child Protection Issues:
Please specify any risk concerns including information pertinent to the CBPS
undertaking home visits:
Please list any documentation you have attached to the referral:
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THANK YOU FOR COMPLETING THE FORM
CBPS Referral Form Version 4, January 2012
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