Eating Disorder Service for children and young people - self referral form

To refer into our Eating Disorder Service for children and young people, fill in the form below.

Full name Required

Date of Birth Required

Height (cm) Required

Weight (kg) Required

Gender Required

Email address Required

Address Required

Postcode Required

Phone number Required

Home phone number

Are you the person who is experiencing these symptoms or is it regarding a child you care for? Required

Name of parent/carer

Parent/carer telephone number

GP address Required

Are you open to other services? (If yes then please name the other service).

Please describe your current difficulties: Required

Risk to self/others, self harm, suicidal behaviour, safeguarding, bullying, abuse, trauma, or neglect.

Do you believe you (or the young person you are completing the form on behalf of) have any current risk? Required

Have you informed your parents/carer about this referral? Required

Have you discussed this referral with your child? (if applicable) Required

By ticking this box, I consent for this information to be released Required

I consent

I agree to the privacy policy

You might also be interested in...