Eating Disorders Service Eating Disorders Service
The Red House Eastern and Coastal Area Office
22 Oakapple Lane Littlebourne Road
Maidstone Canterbury
Kent ME16 9NW Kent CT1 1AZ
Tel: 01622 729980 Tel: 01227 812377
Fax: 01622 729677 Fax: 01227 812268
PRIMARY CARE EARLY INTERVENTION REFERRAL FORM
****PLEASE COMPLETE EVERY PART OF THIS FORM IN AS MUCH DETAIL AS POSSIBLE.**** ****INCOMPLETE FORMS WILL NOT BE PROCESSED AND WILL BE RETURNED TO THE REFERRER.****
Name: Date of Birth: NHS No:
Address:
Marital Status Ethnicity
(This is a mandatory requirement of the Department of Health)
Telephone No: Mobile Telephone No:
Registered GP: Telephone No:
GP Address:
Use the “SCOFF” questions to identify possible cases of eating disorder:
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone in a three-month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say that Food dominates your life?
Score one point for every “yes”; a score of two or more indicates
a likely case of eating disorder.
Assessment
Weight Height BMI Menstruation
BMI calculation: (weight (Kg) ……………..
[height (m)]2
No / Yes / FrequencyPer day / Per week
Missing meals
Restricting meals
Binge eating
Vomiting
Laxatives
Diuretics
Excessive exercise
Substance misuse (specify)
Length of history ……………………………(if over 18 months do not use this form, instead refer to secondary mental health services)
Name of referrer: Title:
Signature: Date of referral:
Kent and Medway NHS and Social Care Partnership Trust
Eating Disorders Service
The Red House,
22 Oakapple Lane, Maidstone, Kent, ME16 9NW
Tel: 01622 729980 Fax: 01622 729677
Eastern and Coastal Area Offices,
Littlebourne Road, Canterbury, Kent , CT1 1AZ
Tel: 01227 812377 Fax: 01227 812268
CRITERIA FOR REFERRAL FOR PRIMARY CARE EARLY INTERVENTION
The criteria for referrals for Primary Care Early Intervention to the Eating Disorders Service at this time are as follows:
· Patients have not had symptoms for more than eighteen months
· There has not been a diagnosis of an eating disorder
· Patients are aged fourteen years or over
Primary Care Early Intervention is for people who GPs suspect may have, or be developing, anorexia or bulimia. Each case will be looked at on an individual basis.