Please Post Or Email Your Completed Referral Form To

Community Eating Disorders Service for Children and Young Peoplereferral form for GPs and other professionals

Please post or email your completed referral form to:

Postal address: Community Eating Disorders Service for Children and Young People, South Kensington and Chelsea Mental Health Centre, First Floor, 1 Nightingale Place, London, SW10 9NG

Email:

You may wish to email or telephone us for a consultation before making a referral. You can call us on: 020 3315 3369

Name of child / young person

Section 1: Children / young person and family details:

Forename
Surname
Also known as
Date of birth
Age
Gender / Male Female
Ethnicity
First language
Home address (including post code)
Telephone or contact details
Current educational setting including name and address (if not referrer)
Telephone or contact details for educational setting
Current General Practitioner (GP) name and address
Telephone or contact details or GP
Child / young person’s NHS number
Is child / young person aware of the referral? / Yes No
Did the child / young person consent for this referral? / Yes No
Please give details about the child / young person’s parents / main carers?
Name / Relationship / Contact details / Parental responsibility?
Yes No
Yes No

Section 2: Identify needs and concerns

The referrer:

Why are you making this referral?
(Please provide detailed history of concerns, rate of weight loss, current height (cm) and weight (kg) and any other information that will aid the team in assessing the referral. Include relevant or educational information)

Child / young person:

What do you want to happen as a result of this referral?

Principal parents / carers:

What do you want to happen as a result of this referral?

Section 3: Other agencies involved

Please tick if any of the following are working with / have worked with the child / young person / family:

Nursery / Pre-School / CAMHS / Connexions Personal Adviser
School Nurse /
Learning Disabilities Nurse / Home-school Link worker / Youth Offending Team
Social Worker / Inclusion /
Learning Support / Educational Welfare Officer
Health Visitor / Education Psychologist / Behaviour Support Services
Other (Please state)

For each agency/organisation currently working with the child / young person / family please provide the following details:

Name / Job Title / Organisation / Telephone number and Email address

Section 4: Referrer’s details

Name
Job title
Agency
Address
Postcode
Contact details
Signature
Date of referral
Has this form been copied to parents / carers? / Yes No

Section 5: Consent

IMPORTANT: Please complete

We would like your consent to contact any one of the agencies/organisations provided on this referral form.

We may also want to contact other agencies that know you, such as your school or GP, to help us to provide a better service to you.

We will ensure that your personal information is kept confidential, unless there are specific concerns that require us to share your details, in which case you will be told of this.

I agree to information being shared between agencies to help me / my child:

Name of child / young person
Signature
Date
Signature of principal
parent / carer
Date

If you do not consent, please state why:

1