PLEASE READ BEFORE COMPLETION OF REFERRAL FORM

If your young person experiences any of the following symptoms please attend your local Children's Emergency Department urgently for a physical health check. Due to dietary restriction or low weight young people may become very physically unwell very quickly so please always be cautious and if in doubt present to your local Children's Emergency Department. 

  • Fainting or collapse
  • No food intake for 48 hours
  • No fluid intake for 24 hours              
  • Chest pain or palpitations              
  • Inability to stand up from sitting    
  • Confusion                            
  • Low body temperature (<36 °C)

We would advise that your GP is made aware that you have a concern about your child’s eating and we will require the following information to enable the team to properly assess the current situation:

  • Weight (include a history of weight records), height, sitting and standing BP and pulse, ECG, a Dexa scan (for girls if no periods for over a year) 
  • Blood test required: Fbc, U+Es, LFTs, calcium, magnesium, phosphate, Vitamin B12, folate, ferritin, TFTs (coeliac screen only if abdominal symptoms)
     

About You

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Child's Details

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Child's Date of Birth Required
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Is this child currently attending school/college? Required
Should we need to; do you give consent for us to contact school for further information? Required

Medical Information

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Has this issue been discussed with the GP? Required
We may need to contact the GP for further information. Do you consent to this? Required
Has the child received any support from Child and Adolescent Mental Health Services (CAMHS) before? Required
Is the child aware that you have contacted our service? Required

Please note

Once we receive your referral a member of the team will contact you on the next working day (Mon-Fri) by telephone. The aim of this will be to discuss your worries further, and decide with you on the appropriate next steps.  If we agree that an assessment with our team would be helpful, we aim to see you within 4 weeks or sooner if needed.  If your referral is not appropriate for our team, we will discuss alternative steps with you.

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