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clinic

Parent / Guardian Details

First Name (Parent/Guardian)*

Last Name (Parent/Guardian)*

Phone Number (Parent/Guardian)*

Email (Parent/Guardian)*

Patient Details

First Name (Patient)*

Last Name (Patient)*

Date of Birth (Patient)*

Eircode*

Additional Information

Provide more details about "My child has had recent thoughts of harming themselves, or has engaged in self-harm or attempted suicide."*

Please elaborate further on your response about your child’s current wellbeing

Provide more details about "My child has needed to go to hospital recently due to a mental health crisis."*

Please elaborate further on your response about your child’s current wellbeing

Provide more details about "My child shows behaviours that place themselves or others at serious risk of harm (for example, aggression or violence)."*

Please elaborate further on your response about your child’s current wellbeing

Provide more details about "My child is currently under the care of CAMHS or another psychiatric service."*

Please elaborate further on your response about your child’s care and support

Provide more details about "My child currently on a waitlist for CAMHS or another psychiatric service."*

Please elaborate further on your response about your child’s care and support

Provide more details about "My child is taking prescribed antipsychotic medication."*

Please elaborate further on your response about your child’s care and support

Provide more details about "My child has ever experienced psychosis, or been diagnosed with a psychotic disorder."*