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 experiencing food issues?: Under 6 Months
6 Months - 1 Year 1 - 2 Years
2 - 3 Years 3 Years Plus

Do you make yourself sick because you feel uncomfortably full?: Yes
No

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

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

Do you believe yourself to be overweight when others say you are underweight?: Yes
No

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

Have you seen your GP about your food issues?: Yes
No

Are you receiving any support for eating disorder?: Yes
No

If yes, what support?:

If yes, where?:

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:

Self Referral Form