Self Referral

We have two different forms to complete depending on who the appointment is for. 

  1. If you are supporting a family member or friend who has an eating disorder and you need some support for yourself then please click here to make an appointment.
  2. If you are suffering from an eating disorder and are making an appointment for yourself, please complete the self referral form below. 

Self referral form

Name *
Name
How long have you been experiencing food issues? *
Do you ever make yourself sick after eating?
Are you purging (making yourself sick, exercising in excess of an hour/using laxatives) more than 5 times per week?
Tick all that apply
Do you ever restrict the amount of food you eat on purpose?
Do you worry that you have lost control over your eating?
Have you lost or gained a stone (14lb/6kg) over the last three months?
Do you ever use exercise as a way of coping with difficult thoughts and feelings?
Do you believe yourself to be overweight when others say you are underweight?
Do you ever eat large amounts of food to help you cope with difficult thoughts and feelings?
Would you say that food dominates your life?
Have you seen your GP about your food issues?
Are you receiving any support from other services i.e CMHT, CAMHS etc for an eating disorder or other difficulties? *