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Adult Eating Disorder Service self-referral form

Self-referral form

When completing this form

Before completing the form, please note that our service offers psychological therapy for people experiencing symptoms of eating disorders (Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder and other specified feeding or eating disorders). We are not commissioned to work with people who are experiencing Avoidant Restrictive Food Intake Disorder (ARFID). 

When completing this form, please provide as much relevant detail as possible. Please be assured that there are no right or wrong answers. The information you provide will help us to process your self-referral in a timely and effective way. After submitting this form, we will be in touch with you within the next few days.

Please now complete the form

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Current Eating Disorder symptoms

Do you experience any of the following? (Please select Yes or No for each):

Restricting your food intake and/or trying to exclude food items or food groups from your diet. Required
Binge eating episodes (this means to eat a large amount of food in a small amount of time, often with a feeling of a loss of control and guilt) Required
Self-induced vomiting Required
Do you exercise in a driven way to influence your weight and/or shape? Required
Do you use laxatives? Required
Do you use diuretics? Required

About your physical health

Please note that we will use your answers to the following questions to plan your treatment, if we decide our service is right for you. They will not be taken into account when deciding whether or not our service is right for you. 

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About your mental health history

Have you previously received treatment for an eating disorder? Required
Are you currently receiving any treatment for a mental health condition? Required
Required

Communicating with you

What is your preferred method for us to contact you? Required
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If your first language isn't English, do you need an interpreter?

And finally, the confidentiality disclaimer

Please read the points below and then confirm you have done this, and that you agree to it all, by ticking the box at the end.

  • 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

Please note, we may need to contact you to ask for more information to determine whether we are the right service to support you.