Make a Referral

Professionals can refer either using the referral form below, or by telephone on 020 3228 2545, during office hours. Children and adolescents need to be under the age of 18 and with a GP in one of the following South London boroughs: Bexley, Bromley, Croydon, Greenwich, Lambeth, Lewisham and Southwark.

For all accepted referrals we aim to offer a first appointment within 28 days


Before we get started

Please respond to the following questions to the best of your knowledge.

Only the questions marked with * are mandatory but all questions will help 
us respond to you in the best way.

If you encounter any difficulty using this service or if you prefer, you can also contact us on our referral phone line 
at the following number: 020 3228 2545

Please provide the following information about yourself:


Please provide the following information about the patient you would like to refer:

Patients date of birth *

If you don’t know their GP surgery’s postcode, the 
NHS GP finder is an easy way to get it.


Please let us know how to contact the patient or their family.


Clinical Information

Has the patient’s weight changed over the last month? *

Periods *

Has the young person experienced any of the following ? *

Please select below

What are the domains of risk? *


* Required field* Required field – we still need information in the following sections* Sorry, this service is for under-18’s only

Overview

Your details

Edit
What type of referrer are you?
Your full name
Your job title
Your organisation
Your telephone number
Your email address

Your Patient

Edit
Patient’s name
Patient’s date of birth
//
Patient’s gender
What is their GP’s name?
What is their GP surgery’s address?
What is their GP surgery’s postcode?
Has this referral been discussed with the patient?
Has this referral been discussed with the parent or carer?

Point of Contact

Edit
Contact’s name
What is their relation to the patient?
Contact’s phone number
Contact’s alternative phone number

Clinical Information

Edit
Please summarise your concerns for the patient
What is the patient’s current (or last recorded) height in cm?
What is the patient’s current (or last recorded) weight in kilograms (kg) or stones (st.) & pounds (lbs.)
Has the patient’s weight changed over the last month?
Periods

Has the young person experienced any of the following?
How would you rate this person’s physical risk level?
What are the domains of risk?
What is the likely diagnosis?
Is there anything else that you would like us to know?

Please make sure all of the information is correct before submitting the form


Your privacy is important to us. To understand how we collect and use your data please read our Privacy Policy

Congratulations!

Your referral has been submitted, What happens next?

Once submitted, this form will be reviewed by a clinician within one working day. We will contact you if we need more information, or 
make direct contact with the patient’s family to suggest an in-person assessment date.

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