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 to enable referrals to be appropriately screened.

Questions marked with a * are mandatory.

Please provide the following information about yourself:

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

Patients date of birth *

Use https://www.nhs.uk/service-search/find-a-GP if you are unsure of the postcode

Has this referral been discussed with the patient? *

Has the referral been discussed with the young person’s parent/carer? *

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

Clinical Information

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

Has the patient been experiencing any of the following in the last month? Select only those that apply *

Do you have any concerns about risk? Select any that apply *

* 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 organisation address
–
Your telephone number
–
Your email address
–

Your Patient

Edit
Patient’s name
–
Patient’s date of birth
–/–/–
Patient’s gender
–
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

Edit
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

Edit
Please summarise your concerns for the patient
–
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? (please specify if gained or lost)
–
Has the young person experienced any of the following?
–
Do you have any concerns about risk?
–
Please provide details of any risk. Explain as fully as possible.
–
Has the young person ever received treatment for a feeding or eating disorder before?
–
If yes, please provide details
–
Has the young person ever been referred to CAMHS or any other mental health professional?
–
If yes, please provide details
–
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.

Please view our Terms and Conditions.

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