Eating Disorders Service Eating Disorders Service

The Red HouseEastern and Coastal Area Office

22 Oakapple LaneLittlebourne Road

MaidstoneCanterbury

Kent ME16 9NWKent CT1 1AZ

Tel:01622 729980Tel: 01227 812377

Fax:01622 729677Fax: 01227 812268

Secondary Care Referral Form

Patient Name:...... Date of Birth:......

Address:......

Marital Status………………………………….Ethnic origin………………………………………………..

(This is a mandatory requirement of the Department of Health)

Telephone No:…………………………………………...Mobile Telephone No:......

Registered GP:...... NHS No:......

Community Consultant Psychiatrist:......

Address:......

......

......

Care Co-ordinator:...... Telephone No:......

Is the patient on enhanced CPA?YesNo

Previous contact with Eating Disorders Service?YesNoDon’t know

Patient’s current weight (in Kg):...... Patient’s current height (in cm):......

Patient’s current BMI: (weight (Kg) …………………….

[height (m)]2

Frequency of abnormal eating behaviours over the previous four weeks:
Not at all / Up to 1 x a week / Once a week / Twice or more a week / Daily / Several times a day

Bingeing
Vomiting
Laxatives
Food restriction, i.e., calorie intake < maintenance needs
(2,000 calories for women)
Diuretics
Excessive Exercise
Other: ………………….. / 1 / 2 / 3 / 4 / 5 / 6

Patient Name: ………………………………………………..

History of previous suicide attempts:YesNoDon’t know

Current thoughts or plans, which indicateYesNo Don’t know there is a risk of suicide:

Current problems with alcohol or substance misuse:YesNoDon’t know

Current psychological co morbidity (i.e., does patient fulfil criteria for another concurrent mental disorder:

Name of referrer:...... Title:......

Signature:...... Date of referral:......

Chairman – Andrew Ling

Chief Executive – Angela McNab

Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, KENT, ME16 9PH

Tel: 01622 724100 Fax: 01622 724167

Kent and Medway NHS and Social Care Partnership Trust

Eating Disorders Service

The Red House,

22 Oakapple Lane, Maidstone, Kent, ME16 9NW

Tel: 01622 729980Fax: 01622 729677

Eastern and Coastal Area Offices,

Littlebourne Road, Canterbury, Kent, CT1 1AZ

Tel: 01227 812377Fax: 01227 812268

CRITERIA FOR REFERRAL FROM SECONDARY MENTAL HEALTH

TO THE EATING DISORDERS SERVICE

Eligibility criteria fro secondary care services are:

Patient is registered with a GP in Kent and Medway

Patients who have a primary diagnosis of an eating disorder or who appear to meet the diagnostic criteria AND

Body Mass Index (BMI) of 17.5 or less OR

Patients who are vomiting daily or taking laxatives to the extent that this causes severe diarrhoea or electrolyte imbalance.

Less severe bulimia but with concurrent medical problems or events which may be affected by their eating disorder, such as diabetes or pregnancy.

The Service is unable to accept referrals of patients with binge eating disorder or simple obesity.