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Community Eating Disorder self referral form

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Email Address

Reference Number

Verification Code (Please enter the code emailed to you)

Northamptonshire Eating Disorder Service is currently not commissioned to offer routine assessment/treatment for ARFID (Avoidant Restrictive Food Intake Disorder). If you think that you meet the criteria for ARFID we recommend that you visit your GP to discuss options. You may also find the following resources/ organisations helpful.

Picky Eaters Recovery Book, Overcoming Avoidant Restrictive Food Intake Disorder by Jennifer Thomas, Kamryn Eddy and Kendra Becker
ARFID Awareness UK https://www.arfidawarenessuk.org/
BEAT, UK Eating Disorders Charity https://www.beateatingdisorders.org.uk/get-information-and-support/about-eating-disorders/types/arfid/
Hummingbird - Online ARFID Support Group 'Hummingbird' run by BEAT every Sunday 18:45 to 19:45 https://www.beateatingdisorders.org.uk/get-information-and-support/get-help-for-myself/i-need-support-now/online-support-groups/arfid-support-group/
The Nutrients of Human City by Oliver Street
ARFID Avoidant Restrictive Food Intake Disorder: A Guide for Parents and Carers by Rachel Bryant-Waugh

Section 1 - Person Submitting Information

*First Name

*Last Name

*Email Address

*Address

*Date of Birth

*Name and Address of GP

Current Medication

*Description of Eating Difficulties and Reason for Referral

*To enable our service to process your self-referral we would need your permission to liaise with any professionals involved in your care, including your GP. Please tick this box to confirm you give consent for our team to contact those relevant professionals.

Do you have any weight and shape concerns?

*What is your current weight? (please type "Not Known" if you are unsure)

Is your weight:

Please inform us of the rate of weight loss/increase (KG or stones/lbs per week)

Height

Are you self-inducing vomiting?

Please tell us the frequency of self-inducing vomiting

Are you taking laxatives?

Please tell us the frequency of taking laxatives

Are you binge eating?

Please tell us the frequency of binge eating

Are you taking weight loss injections?

Please tell us the duration of this

History of Previous treatment for any mental health difficulties

History of eating difficulties

Please provide any further information that would be helpful for us to be aware of to support your referral.

Any attachments for reference

NHFT Referral Forms

Community Eating Disorder self referral form

Please select from the following before proceeding

Section 1 - Person Submitting Information

Thank you for your submission.