Make a Referral

Professionals should refer using the referral form below, preferably in consultation with their patient/family. This referral form is only to be used for children and adolescents under the age of 18 and registered with a GP in one of the following 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. This information is important to enable us to screen referrals, therefore information needs to be as full and as accurate as possible. Questions marked with a * are mandatory.’

REFERRALS WITHOUT CURRENT BLOOD RESULTS WILL BE REJECTED

(Full Blood Count, Renal Profile, Bone Profile, Liver Function Tests, Thyroid Function Tests, Coeliac Screen and Vitamin D)

Blood results should be sent to the following email address at the same time as the on-line referral form is completed – MCCAEDReferrals@slam.nhs.uk

If carrying out blood tests is going to result in life threatening delay in accessing treatment, please outline this on the referral form and a member of the team will contact you.

Overview

Your details

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

Your Patient

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Patient’s name: –
Patient’s date of birth: –/–/–
Patient’s gender assigned at birth: –
Patient’s current gender identity: –
Patient’s ethnicity: –
Patient’s address: –
Their GP’s name/surgery and address: –
Has this referral been discussed with the patient?: –
Has the referral been discussed with the young person’s parent/carer?: –

Point of Contact

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Contact’s name: –
What is their relation to the patient?: –
Contact’s phone number: –
Contact’s alternative phone number: –
Contact’s email address: –

Clinical Information

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Which team would you like this referral to be considered by: –
Please summarise your concerns for the patient: –
Do you believe the young person is intentionally trying to lose weight: –
Has the child/young person been investigated for any possible physical causes of their eating difficulties: –
How long has the patient been experiencing these difficulties?: –
What is the patient’s current or last recorded height in cm?: –
When was this measurement taken?: –
What is the patient’s current or last recorded weight in kilograms (kg)?: –
When was this measurement taken?: –
Has the patient’s weight changed over the last month?: –
If yes, how much weight have they gained or lost in the last month: –
If no weight or height has been taken please explain why this is the case: –
Has the young person experienced any of the following?: –
If self-induced vomiting has been reported please provide further details regarding duration and frequency: –
Do you have any concerns about the following physical health risks?: –
Please provide detailed information relating to these physical health risks to help us understand the urgency of the referral: –
Are there any risks to self?: –
Please provide details of any risk to self, including physical risk related to eating difficulties if not outlined in the last question: –
Are there any risks to others (i.e. violence or aggression)?: –
Are there any risks from others or safeguarding? For example, is there any involvement from social services, either in the past or current?: –

Other Professional Involvement

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Has the young person ever received treatment for a feeding or eating disorder before?: –
If yes, please provide details: –
Does the young person have any other known or suspected medical or psychiatric conditions?: –
Are there any other health professionals currently involved including both NHS or private professionals e.g. Dietitian, Paediatrician, Occupational Therapist, Therapist, Counsellor?: –
Has the young person ever been referred to CAMHS or any other mental health professional?: –
If yes, please provide details of services and professionals involved.: –
Is there anything else that you would like us to know?: –

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

Please email any additional relevant documents here (e.g., reports, results of investigations, recent physical observations): mccaedreferrals@slam.nhs.uk

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Submit

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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.

Please view our Terms and Conditions.

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