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Northamptonshire Adult Eating Disorder Service

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Northamptonshire Eating Disorder Service is currently not commissioned to offer routine assessment/treatment for ARFID (Avoidant Restrictive Food Intake Disorder). We will however consider referrals for patients that are considered ‘high risk’ in terms of weight/ physical health concerns or nutritional deficiencies. If a referral is necessary, we kindly request the following blood results, FBC, LFT, U&E, Bone profile including phosphate, Coeliac Screening, Magnesium, Vitamin B12/folate, Vitamin A, Vitamin C, Zinc, Selenium, random glucose and TSH. If you would like to discuss this further, please contact the service on 03000 270 570.

Section 1 - Referrer Details

*Legal first name of referring GP or referring team

*Legal surname of referring GP or referring team

*Address of referring GP or referring team

*Email address of referring GP or referring team

Service User Information

*Service user's GP name

*Service user's GP address

*Service user first name

*Service user last name

*NHS number

*Service user address

*Service user contact number

*Service user date of birth

*Reason for referral

*Weight and shape concerns

*Is this referral urgent?

*Please give your reason if you selected this as an urgent referral. If you did not please simply state N/A

*Is this referral for yourself?

Physical health

Weight

Height

Blood pressure (BP)

Pulse

*What is their BMI? (weight in kg / height in m²)

Eating disordered behaviours

Please make sure this includes CURRENT frequency of behaviours.

*Vomiting

If you chose yes to vomiting, please fill in what their frequency of vomiting is?

*Using laxatives

If you chose yes to using laxatives, what is their frequency of laxative use?

*Bingeing - (eating a large amount of food in a short time with a feeling of loss of control)

If you chose yes to bingeing, what is their frequency of bingeing?

Is their weight now...

If their weight is falling, what is their rate of weight loss. Please state this in kg/week

Please give details about history including previous treatment

History of eating difficulties

Other information

Please highlight any risks (to self or others)

Current Medication (+ dose)

Any other services involved?

*Is the person aware of this referral?

*Are they motivated to seek help?

*Does the service user speak English?

*Is an interpreter necessary?

What is their preferred language?

Any other information we should be aware of?

Please make sure your upload the correct information.

Blood tests to include: FBC, WBC, LFTs, U & Es, phosphate, magnesium, ESR, Fe studies (additional if BMI less than 17.5 bone profile, cardiac profile, B12/folate)

Upload last month's blood results

If BMI less than 15 please attach recent ECG

Attachments

Please upload any other information relevant for this referral. Please note we accept a maximum of 5 documents, with a maximum 5MB per document, please limit to 5MB per document.

Document Type	Document Name	Upload Docs

NHFT Referral Forms