Eating Disorders Program Referral Queensland Health Staff Use Only (Record patient details or affix patient identification label here) URN: Family name: Given names: Address: Suburb: Postcode: Phone (H): Mobile: Date of birth: Sex: M F O Date: The child/young person has been reviewed by a consultant psychiatrist prior to this referral Yes No The child/young person meets criteria for admission based on guidelines (below) Yes No Assessment and treatment of children and adolescents with eating disorders in Queensland Have you obtained consent for this referral from child/young person’s legal guardian? Yes No Child/young person? Yes No REASON FOR REFERRAL Children’s Health Queensland CYMHS internal referral: Assessment Second opinion Consultation State-wide Child and Youth Mental Health Service For all referrals originating outside CHQ HHS for Assessment for Treatment via Telehealth the child/young person must have a CONFIRMED diagnosis of primary eating disorder by consultant psychiatrist Assessment for treatment of primary eating disorder FBT CBT-E Second opinion – review with family/client and treating team Consultation – case discussion with treating team only Current formulation and summary of delivered care: Diagnosis (provisional / confirmed): Height and weight history (please seek any historical objective recorded weights throughout life): Current medications: Clinical questions for consultation: REFERRER DETAILS Name: Designation/role: Organisation: Provider no: Address: Suburb: Postcode: Phone: Fax: Email:

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Queensland Health and Department of Education staff can submit a referral directly to Children’s Health Queensland Central Referrals Hub by clicking on SUBMIT below, or by FAX: 07 3068 4329

Enquiries to the Eating Disorder Program - Phone (07) 3397 9077, Fax: (07) 3394 4057 or CHQ-CYMHS-EatingDisorders@health.qld.gov.au