Child and Adolescent Enquiry Under 17½ years old Telephone: 01926 803804 Email: adminteam@jmmentalhealth.co.uk Please complete the enquiry form below. *Child's SurnameChild's Surname required *Child's ForenameChild's Forename required *Date of Birth (please note we only take on patients between the ages of 6 and 17 inclusive) Date of Birth (please note we only take on patients between the ages of 6 and 17 inclusive) requiredInvalid date. Expected 'dd/mm/yyyy' or 'dd/mm/yyyy hh:mm' *Address Address required *Primary Contact Full NamePrimary Contact Full Name required *Relationship to ChildRelationship to Child required *MobileMobile requiredInvalid mobile *EmailEmail requiredInvalid 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/AIf you have selected ‘Quickest’ or ‘Video’ above – will your child/young person engage in an online appointment? required 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 NoPlease 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) required *Is your child on a reduced timetable and/or accessing online learning from home?YesNoIs your child on a reduced timetable and/or accessing online learning from home? required 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)?YesNoAre other professionals involved in the care of your child (e.g. Social Services or CAMHS)? required 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? How did you hear about us? If you have been referred by another professional – please state who? required *Please give brief details/background of the issues your child is experiencing Please give brief details/background of the issues your child is experiencing required 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. Please uncheck this box to continue Quality Standard