Kent and Medway All Eating Disorder Service ARFID Referral Form

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Patient Details

* Date of Referral

* Patient Name

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* Age

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* Date of Birth

* Patient Address

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Phone Number

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* Patient email address

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* Sex

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* Gender

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NHSNumber

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* First Language

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* Interpreter Required

Yes No

* Marital Status

Yes No NA

Smoking Status

Smoker Non-smoker Ex-smoker NA

If a young person and in education, please provide name and contact of school/college

Not in education In education NA

Employment Status

EMPLOYED UNEMPLOYED UNABLE TO WORK NOT APPLICABLE

* Is the patient registered Special Educational Needs (SEN)

Yes No NA

* Is the patient Registered Disabled

Yes No

Does the patient have any children/dependents

Yes No

* GP Name

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* GP Address

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* GP Phone Number

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GP Email

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* Patient Ethnicity

Parent/Carer/Next of kin

If under 16, patient consent is not required for information sharing *Gillick competency will be applied

* Parent/Carer/Next of kin name

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* Relationship to patient

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* Contact Address

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Post Code

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Telephone Number

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Email Address

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* Has the patient agreed to service having contact with Parent/Carer/Next of Kin?

Yes No

Patient Difficulties

(NOTE: weight & height are mandatory fields and the referral cannot be processed without this information)

These can be from health visiting (for under 5s), school nursing for children at school. GP or other health appointment measurements if known. Or home measurements if parents/carers able to do this.

* Weight (Kg / Stones & Lb)

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* Height (cm, metres, feet, inches)

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* Weight Change In Last 3 Months Increase / Decrease and amount or state if stable)

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* Any nutritional deficiencies? (e.g, low vitamin B12 etc)

Yes No

Are you /they currently taking ONS / supplements ? (e.g., Fortisip etc)

Yes No

* Describe current concerns around eating (where possible, specify function for avoidance of food – e.g., fear-based, sensory, lack of interest?)

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* Can you provide a brief history of eating (including when potential issues around food / eating started)

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* Have you / they received any professional support around eating OR have any strategies been tried to help improve eating?

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* Relevant Psychiatric and Social History

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* Medical History (including any current medication and doses)

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Additional Information (please reference any available reports)

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Attach 3 day food diary here (document can be found on the ARFID web page - please do not submit this form without the diary)

*this upload is mandatory, for instructions please read guidance at top of form

Risk Factors

* Are there any significant risk factors currently occurring?

Suicidal ideation Previous suicide attempts Self harm Concern for safety of others Other

How are the current risks being managed

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* Do you consider it safe to see this person on a one to one basis?

Yes No

Referrer Details

* Is this a self referral?

Yes No

Referrers name

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Relationship to the patient

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Service/Agency if applicable

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* Contact email

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* Phone number

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Patient Details

Parent/Carer/Next of kin

Consent

Patient related medical information

Patient Difficulties

Risk Factors

Safeguarding and Social Care

Referrer Details