Form: Community+Eating+Disorder+self+referral+form

About me

Note: Questions marked by * are mandatory

Please fill in this form if you would like to self-refer to the Community Eating Disorder Service

We can only accept self-referrals from people who live in Northamptonshire or are registered with a GP within Northamptonshire. Referrals will not be accepted for clients currently seen by another NHFT service.

All referrals will be screened and a clinician within our team will contact you if further information is required If you have any questions please email: neds@nhft.nhs.uk

*This is a mandatory field. Full name

Email address

*This is a mandatory field. Address

*This is a mandatory field. Date of birth

*This is a mandatory field. Name and address of GP

Current medication

*This is a mandatory field. Description of eating difficulties and reason for your referral

*This is a mandatory field. To enable our service to process your self-referral we would need your permission to liaise with your GP. Please tick this box to confirm you give consent for our team to contact your GP

Tick here