Date: SECTION 1 - YOUNG PERSON DETAILS If referring from within CYMHS please complete name and CIMHA ID only in Section 1 and proceed to Section 2 Family name: Given name: Preferred name: Date of birth: CIMHA ID: Sex recorded at birth: Gender: Address: Suburb: Postcode: Phone: Alerts and allergies: Country of birth: Interpreter required? Yes No Preferred language: Indigenous status: Aboriginal Torres Strait Islander Both Neither Medicare eligible: No Yes – Card number: Card reference: Expiry: / Is the young person in ‘out of home’ residential care? Yes No If yes, which Child Safety Service Centre: Contact name: Phone: Is the young person in the guardianship of Department of Child Safety? Yes No Are there any custody or guardianship issues? Yes No If yes, details: Are there current Family Law Court Orders in place? Yes No If yes, details: Is the parent/carer the young person’s legal guardian? Yes No Is the legal guardian the preferred contact? Yes No Have you obtained consent for this referral from young person’s legal guardian? Yes No Have you obtained consent for this referral fromsaxsaxxsxsasxs Young person? Yes No PARENT/CARER DETAILS Parent Legal Guardian Other (specify): Name: Relationship to young person: Address: Email: Contact number: Interpreter required? Yes No Preferred language: Parent Legal Guardian Other (specify): Name: Relationship to young person: Address: Email: Contact number: Interpreter required? Yes No Preferred language: SECTION 2 - HISTORY Current Primary diagnosis: Duration of eating disorder: Secondary diagnoses: Evidence based treatment the young person and/or family are currently engaged in for the eating disorder: FBT-AN CBT-E FBT Informed Case Management Other: When did the family commence treatment? Current frequency of treatment: Weekly Fortnightly Monthly Other: Hospital presentations and admissions: Date/s: Duration: Reason: Date/s: Duration: Reason: Date/s: Duration: Reason: Brief summary of treatment to date: Barriers to treatment progress: Goals for treatment at the CYMHS Eating Disorders Day Program: Current medications: Any current or history of self-harm or suicidality? Yes No If yes, provide details: EDUCATION – young person must be enrolled in a registered education program) Name of school: Year level: Frequency of attendance: Details of supports needed at school: PHYSICAL EXAMINATION – please attached weight chart if available Current height: Date: Current weight: Date: Weight and height at commencement of treatment: Date: Current Expected Body Weight range (if known): How frequently does the young person see their GP for medical monitoring? Is the young person medically stable? Yes No Provide most recent medical monitoring Menstrual history Is the young person currently menstruating? Yes No Did the young person commence menstruation by 15 years? Yes No Has the young person’s menstruation ceased in context of eating disorder behaviours? Yes No If yes, please provide date range: FORMULATION Provide history and description of presenting eating disorder – including predisposing, precipitating, and maintaining factors. Eating Disorder Behaviours: Restricting - provide details: Reduced/rigid food repertoire - provide details: Excessive exercising - provide details: Purging/vomiting - provide details: Bingeing details - provide details: Laxatives details - provide details: HISTORY OF COMORBID OR OTHER MENTAL HEALTH ISSUES OTHER RELEVANT PERSONAL AND FAMILY HISTORY Please provide details of relevant developmental history, significant life events for the young person and their family, family history of mental illness, family functioning) OTHER SERVICES / TREATING PROVIDERS CURRENTLY INVOLVED Name: Agency: Contact number: Name: Agency: Contact number: Name: Agency: Contact number: Name: Agency: Contact number: REFERRER DETAILS Name: Designation/role: Organisation: Provider no: Address: Suburb: Postcode: Phone: Fax: Email:

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External to Queensland Health please consider the Privacy Obligations for secure sending of Health Information Please FAX your completed form to: 07 3068 4329
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

For more information please contact the Child, Youth and Mental Health Service Day Program on (07) 3084 2100 or review the referral guidelines at Child and Youth Mental Health Service – Eating Disorders Program