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Taking the first step can feel daunting, but you’re in the right place. Our referral form is quick to complete, and it helps us understand how best to support you. Once submitted, we’ll contact you to talk through what happens next.

Date of Referral*

Is this referral for you or someone else?*

Myself

Someone else

First name*

Last name*

Phone*

Email*

Birthday

Day

Month

Year

Address including postcode*

NHS Number (if known)

Doctors name (if known) and GP address and postcode*

What challenges have you been experiencing that you’d like support with?*

Do you consider your referral to be urgent?*

Yes

No

Height*

Weight*

BMI (if known)*

Have you received any medical or mental health diagnoses? If so, please share them here.*

Are you currently taking any prescribed, over-the-counter, or non-prescription drugs? If yes, please provide details below.*

Are you current self inducing vomiting? If yes please provide details*

Are you using laxatives? If yes please provide details*

Are you currently using any other purging methods e.g., diet pills, weight loss injections? If yes please provide details *

Do you eat large amounts of food in a short space of time or when you are not hungry? If yes please provide details*

Do you restrict your daily food/ calorie intake? If yes please provide details*

Do you excessively exercise? If yes please provide details*

Is your weight over the last month*

Stable

Falling

Increasing

Unsure

If applicable, rate of weight loss*

Have you ever been previously diagnosed with an eating disorder? If yes please provide details*

Have you ever been under the care of psychiatric services? If yes please provide details *

Are you currently receiving any other interventions? If yes please provide details*

Do you have any long-term health conditions or learning difficulties that it would be helpful for us to be aware of?*

Gender identity*

Biological woman

Trans woman

Biological man

Trans man

Non-binary

Other

Prefer not to say

Sexual orientation*

Heterosexual/Straight

Homosexual/Gay/Lesbian

Bisexual

Pansexual

Asexual

Queer

Other

Prefer not to say

Ethnicity*

Asian British

Bangladeshi

Chinese

Indian

Pakistani

Other Asian Background

African

Black British

Caribbean

Other Mixed or Multiple ethnic group

English

Gypsy or Irish Traveller

Irish

Northern Irish

Scottish

Welsh

Other European

Other White background

Arab

Other ethnic group

Prefer not to say

Religion*

No religion or belief

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

Other religion or belief

Prefer not to say

Any other relevant information to your referral?*

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Email*

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