In this section you will find guidance around CNEST ratings and clinical recommendations. 

Final risk stratification 

For the final risk stratification, use the rating for the section A and section B in the following matrix to get the final rating. The purpose of the tool is to do a risk stratification considering relative risks; it does not replace individual risk assessments.

  Section B: Impacting Factors
High Medium Low
Section A: Complex Risk Factors High High High Medium
Medium High Medium Low
Low Medium Low Low

Once you have the final risk stratification you will be able to access which clinical recommendation to use this will be HIGH, MEDIUM or LOW. You can find the clinical recommendations in the tool by using the tabs along the bottom. 


We have also included the clinical recommendations below:

A CNEST rating of high means that if there is no increased response from the multiagency system around the young person and family, and their needs remain unmet, it is very likely the young person will require admission to a Tier 4 CAMHS unit or present at A&E in mental health crisis.  The clinical presentation is considered severe, and the young person may require urgent specialist and high intensity intervention(s).

The needs of the young person identified as high risk, should be taken to the relevant multi-disciplinary team meeting and follow service escalation procedures.  The young person’s needs should also be discussed at the place-based Gateway Meeting. This meeting aims to ensure that all agencies take collective responsibility for the care and welfare of young people at risk of admission to Tier 4 CAMHS and meet any identified unmet needs as a matter of urgency.   

Consider a Care Education and Treatment Review (CETR) if the young person has a learning disability and / or Autism.

To facilitate this discussion, please ensure all recommendations below (i.e. for medium and low risk) have already been considered and completed as appropriate.

A CNEST rating of medium means that there is a possibility of Tier 4 CAMHS admission. The young person’s presentation is concerning and could still worsen. There is a risk that this young person will move into ‘high risk’ rating, if there is not a review of the multiagency package of care to ensure that all appropriate actions and interventions are being put in place. At this level of risk, clinicians should ensure the following steps have been considered and completed as appropriate:

  • Consider consultation with Tier 4 CAMHS Assessment and Outreach Team
  • Consider input from Crisis Services and Intensive Support Functions
  • Review the formulation, care plan and associated safety plans are in place, with all agencies involved.
  • All relevant clinical and safeguarding assessments have been completed – this may require expedition.
  • Use of internal and multiagency escalation policies where there is disagreement or concern regarding multiagency input.

Please ensure all recommendations below (i.e., for low risk) have already been considered and completed as appropriate.


A CNEST rating of low means the young person has identified needs requiring specialist children and young people mental health service intervention and their needs are currently been met by appropriate services.

For young people at all levels of risk:

  • Ensure a formulation and associated care plan is in place. This should be developed collaboratively with the young person and family as appropriate and any associated agencies.
  • Case Manager/Keyworker is allocated by the service to the young person.