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PLEASE READ BEFORE COMPLETION OF REFERRAL FORM

If your young person experiences any of the following symptoms please attend A&E urgently for a physical health check. Due to dietary restriction or low weight young people may become very physically unwell very quickly so please always be cautious and if in doubt present to A&E

  • Fainting or collapse
  • No food intake for 48 hours
  • No fluid intake for 24 hours              
  • Chest pain or palpitations              
  • Inability to stand up from sitting    
  • Confusion                            
  • Low body temperature (<36 °C)

We would advise that your GP is made aware that you have a concern about your child’s eating and we will require the following information to enable the team to properly assess the current situation:

  • Weight (include a history of weight records), height, sitting and standing BP and pulse, ECG, a Dexa scan (for girls if no periods for over a year) 
  • Blood test required: Fbc, U+Es, LFTs, calcium, magnesium, phosphate, Vitamin B12, folate, ferritin, TFTs (coeliac screen only if abdominal symptoms)
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Has this issue been discussed with your GP? Required
We may need to contact your GP for further information to help with your referral. Do you consent to this? Required
Do you currently attend school/college/employment? Required
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Should we need to; do you give consent for us to contact school for further information? Required
Are your parents/carers aware that you have contacted our service?
Do you give us permission to contact them? Required

If Yes, please give details:

If you do not consent to your parents being contacted currently, we may need to talk with you further and agree a plan. There may be times we may need to make your parents aware, depending on your age and circumstances. We will not contact them without your knowledge

Please note:

Once we receive your referral a member of the team will contact you on the next working day (Mon-Fri) by telephone. The aim of this will be to discuss your worries further, and decide with you on the appropriate next steps.  If we agree that an assessment with our team would be helpful, we aim to see you within 4 weeks or sooner if needed.  If your referral is not appropriate for our team, we will discuss alternative steps with you.

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