Syeda - A regional charity that supports anyone affected by an eating disorder

Name: *

Address 1:

Address 2:

Town/City:

Postcode:

Telephone: *

Email: *

Date of Birth:

How long have you been supporting somebody with an eating disorder?: Under 6 Months
6 Months - 1 Year 1 - 2 Years
2 - 3 Years 3 Years Plus

What support, if any, do you receive with these issues?:

What are your main concerns and reasons for seeking help?:

How is your life affected by your role as a carer?:

Do you worry they have lost control over how much they eat?: Yes
No

Have they recently lost or gained more than 1 stone in a 3 month period?: Yes
No

Would you say that food dominates their life?: Yes
No

Have they seen their GP about their eating disorders?: Yes
No

When is the best time to contact you to make an appointment?: Morning Afternoon
Evening Anytime

What is your preferred method of contact?:

General Comments:

Carers Referral Form