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Clinic

First Name (Parent/Guardian)*

Last Name (Parent/Guardian)*

Phone Number (Parent/Guardian)*

Email (Parent/Guardian)*

First Name (Patient)*

Last Name (Patient)*

Date of Birth (Patient)*

Reason for Appointment*

Enter reason for Appointment*

Upload previous diagnosis reports (PDF)*

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Document(s) Password (if required)

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Your message (optional)

About your child’s current wellbeing

My child has had recent thoughts of harming themselves, or has engaged in self-harm or attempted suicide.

My child has needed to go to hospital recently due to a mental health crisis.

My child shows behaviours that place themselves or others at serious risk of harm (for example, aggression or violence).

About your child’s care and support

My child is currently under the care of CAMHS or another psychiatric service.

My child currently on a waitlist for CAMHS or another psychiatric service.

My child is taking prescribed antipsychotic medication.

About your child’s needs

My child has ever experienced psychosis, or been diagnosed with a psychotic disorder.

My child has an active, untreated eating disorder.

My child has a diagnosis of moderate or severe intellectual disability.

My child has severe anxiety that prevents school attendance.

My child has depression that significantly affects daily functioning.

My child is autistic and requires high levels of support.

My child has severe school refusal with an educational support plan in place.

Additional considerations

My child is currently experiencing significant difficulties with alcohol or drug use.

Please specify other concerns:

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Request Confirmation of Diagnosis Appointment