Child and Adolescent Enquiry Under 17½ years old Telephone: 01926 803804 Email: adminteam@jmmentalhealth.co.uk Please complete the enquiry form below. *Child's Surname *Child's Forename *Date of Birth (please note we only take on patients between the ages of 6 and 17 inclusive) *Address *Primary Contact Full Name *Relationship to Child *Mobile *Email *Which type of appointment would you prefer? Select one of the options from the drop down list No preference, I would accept the quickest option All appointments face-to-face in Leamington Spa All appointments by video Initial appointment face-to-face with follow up appointments by video *What is your second choice of appointment type? Select one of the options from the drop down list I would only accept my first choice of appointment type No preference, I would accept the quickest option All appointments face-to-face in Leamington Spa All appointments by video Initial appointment face-to-face with follow up appointments by video *If you have selected ‘Quickest’ or ‘Video’ above – will your child/young person engage in an online appointment?YesNoN/A Please provide any additional information regarding your child/young person’s engagement with online appointments *Please confirm that you shall be funding the appointment yourself (please note that we no longer take on patients that are claiming through an insurance company)Yes No *Is your child on a reduced timetable and/or accessing online learning from home?YesNo If you answered yes to above question, please give details *Are other professionals involved in the care of your child (e.g. Social Services or CAMHS)?YesNo If you answered yes to the above question, please give details *How did you hear about us? If you have been referred by another professional – please state who? *Please give brief details/background of the issues your child is experiencing Please only enter your email here if you are not a real person. PhonePlease enter your phone number here if you are a robot. When you're ready to send the form, uncheck this box and continue. This helps keep our forms secure. Quality Standard