Child/Young person’s details
First name
* Required
Family name
* Required
NHS number
Date of birth
* Required
Age
* Required
Ethnicity
* Required
Religion
* Required
Gender
* Required
Preferred pronouns
* Required
Preferred name
* Required
Address
* Required
Home phone
Mobile phone
Work phone
E-mail address
* Required
Does the child/young person or family members / carer have any physical or communication needs? Especially in regards arranging/attending appointments?
* Required
Yes
No
If yes, please provide details of needs and adjustment requested
Are there any other considerations, such as culture, language, illness, religion or disability, when making contact with the Child / young person or family members / carers?
* Required
Yes
No
If yes, please provide details:
Family / Carer Details
Name of parents/carers
* Required
Relationship to child / young person
* Required
Address (if different from young person)
Contact Details (if different from young person)
Who holds parental responsibility Please give contact details if not already shown above.
* Required
Is the child / young person “looked after” as defined in the Children’s Act 1989?
* Required
Yes
No
Are there any Safeguarding concerns?
* Required
Yes
No
If yes, please give details:
Is the child / young person adopted?
* Required
Yes
No
Is the child / young person subject to Child Protection Plan?
* Required
Yes
No
GP details
GP name
* Required
GP address
* Required
GP telephone number
* Required
GP e-mail address
* Required
Consent
Has the referral been discussed with parents/carers (who have parental responsibility)?
* Required
Yes
No
If No, please give details:
Do the parents/carers (who have parental responsibility) consent to this referral?
* Required
Yes
No
If No, please give details:
We may need to contact any of the organisations mentioned in the referral, including GP and school. Has the parents/carers (who have parental responsibility) consented to contact these organisations?
* Required
Yes
No
If No, please give details:
Has the referral been discussed with Child / young person?
* Required
Yes
No
If No, please give details:
Does the child / young person consent to this referral?
* Required
Yes
No
If No, please give details:
We may need to contact any of the organisations mentioned in the referral, including GP and school. Has the child / young person consented to contact these organisations?
* Required
Yes
No
If No, please give details:
Physical health
Please respond to risks as appropriate including consideration of paediatric admission if clinically indicated.
Physical health check: Remove shoes, coat, jumper and items from within pockets.
Recent physical health check?
* Required
Yes
No
Carried out by:
Weight (kg)
* Required
Height (cm)
* Required
BP Sitting
* Required
BP Standing
* Required
Temperature Tympanic
* Required
Pulse Sitting
* Required
Pulse Standing
* Required
Allergies, please provide details
Medical Conditions, please provide details
Blood Investigation & results FBC, U&Es, LFTs, Phosphate, Thyroid Function Tests, bone profile, cardiac profile, B12/folate).
Other Physical Health causes which may influence the condition, please provide details
Other Investigations & Results, please provide details
Historical Changes in Height and Weight
Date
Height
Weight
Date
Height
Weight
Date
Height
Weight
Current Presentation
Mental Health Concerns
Mental health concerns, including self-harm / suicidal ideation/behaviour
* Required
Yes
No
If yes, please provide details:
Please consider contacting the crisis service if there are significant concerns in this area.
Telephone: 0800 6522865
Eating disorder behaviour and symptoms
Trying to change weight or shape?
* Required
Yes
No
If yes, please provide details:
Current Presentation – Please contact us if concerned about risk
Behaviour, please select all that are relevant
Vomiting
* Required
Yes
No
If yes, please provide details
Restricting intake
* Required
Yes
No
If yes, please provide details
Limiting variety of food
* Required
Yes
No
If yes, please provide details
Using laxatives
* Required
Yes
No
If yes, please provide details
Other purging methods, diet pills, etc
* Required
Yes
No
If yes, please provide details
Bingeing
* Required
Yes
No
If yes, please provide further details
Excessive exercise
* Required
Yes
No
If yes, please provide further details
Body image issues
* Required
Yes
No
If yes, please provide further details
Any other Information, please provide details
Periods
Have child/young person’s periods started?
* Required
Yes
No
If yes, what age did they start?
How regular are they?
* Required
Mostly regular
On and off
Stopped
N/A
If stopped or on and off, when was the last period?
Is child/young person using any medication which may affect menstrual cycle?
* Required
Yes
No
If yes, what type?
Further information
Please provide any further information affecting the child / young person not mentioned above
