Eating Disorder Service - Self-referral form

Self-referral form

Confidentiality Disclaimer

We will ask personal information to help us to deliver the best possible care. Everyone working for the NHS has a legal duty to maintain confidentiality.
All information will be kept in a ‘healthcare record’ on the trust’s computer system. Occasionally we may also use paper records. We’ll do everything we can to keep information you share safe.
Sometimes we need to talk to staff from other agencies (e.g. school, GP, social workers.) Anyone who received any information from us also has a legal duty to keep this confidential.
We will not share information without your prior agreement or knowledge unless the health and safety of yourself or others is at risk or if we are required by law under the Data Protection Act 2018.
You have a right to see and comment on any of the information we hold about you. If you do have any concerns or queries about this then please discuss this with the staff member you are in contact with.
Further information about our legal framework for processing your information is detailed on our Trust website privacy policy and ‘How we use and share your information to help you’ leaflet.
If you do not wish to have your records accessed for research purposes, please visit https://digital.nhs.uk/services/national-data-opt-out-programme to set your choices.

I understand that this referral will be looked at by the Eating Disorder Service, and I will be kept informed of what happens next.

I confirm I have read and agree to the above Confidentiality Disclaimer. Required

Yes

Forename Required

Surname Required

Preferred name (if different to full name)

Preferred pronouns

Date of birth Required

Email address Required

Contact number Required

Address Required

Please tell us why you would like help from our Eating Disorders Service Required

Please tell us about your eating difficulties Required

How long have you experienced these difficulties? Required

Your height

Your weight

Your BMI (if known)

Name of your GP surgery Required

Has this problem been discussed with your GP? (Please be aware we will contact your GP for details of any recent physical health checks, or if you have not attended recently regarding this problem, we may request that you attend your GP for these reasons) Required

Are you currently under the care of any other service? (This includes both mental or physical health services). If so, please state below. Required

Eating Disorder Service - Self-referral form

Self-referral form

Confidentiality Disclaimer

Trust Headquarters

Useful Links

Eating Disorder Service - Self-referral form

Self-referral form

Form

Confidentiality Disclaimer

Trust Headquarters

Useful Links

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