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Community Disordered Eating Team (Adults) Referral form

Referral form

Community Disordered Eating Team (Adults) 
This service is for residents of East London Foundation Trust (Newham, Tower Hamlets, and City & Hackney) or whose GP is in one of the aforementioned Boroughs. For those living in other London Borough’s please see the local website.

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We understand that these forms can sometimes feel difficult to fill in. The aim of this form is to enable us to direct you to the most appropriate support for you. Your answers are not ‘final’ and will be discussed in more detail at your initial appointment. You may or may not find that some of the questions do not feel relevant to your personal experience. Answering ‘no’ or ‘not at all’ to some questions does not mean that you will not receive help. We offer a range of services, and answering as honestly as possible will help us to work with you to decide which support is best for you.

Everything you tell us is kept confidential, unless you disclose information concerning current or potential harm or risk to yourself or another person, then we will need to inform the relevant agencies/health professionals to ensure that the right support is provided.

By referring yourself to this service you are agreeing that the service may contact and share relevant information with your GP to facilitate your care. This self-referral form will take approximately 10 minutes to complete. Please provide as much information as possible as this will speed up the process.

1. Please confirm that you agree with these terms and conditions:
5. Gender
7. What Borough do you live in?
11. In which Borough is your registered GP practice?
13. Permission to contact by: (please select all that apply)
14. Are you pregnant or do you have a child under 12 months?
15. Are you a member of the armed forces community?
16. When did your difficulties around eating start?
Please answer the following questions thinking back to the last six months
17. Has thinking about food, eating or calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation or reading)?
18. Do you make yourself sick?
If yes, how often?
19. Do you exercise in a ‘driven’ or ‘compulsive’ way as a means of controlling your weight, shape or amount of fat or to burn off calories?
If yes, how often?
20. Do you ever eat what other people would regard as an unusually large amount of food?
21. How often do you eat in secret?
22. Do you ever deliberately try to limit the amount of food you eat to influence shape or weight (whether or not you do this)?
If yes, how often?
23. Do you believe that your life would be better if you were a different size, weight or shape?
24. Do you use laxatives, diuretics or any other substances or medications in the hope of controlling your weight?
If yes, how often?

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You can include how concerns with food, shape or weight is impacting you at the moment. What is the result of your experiences, how does this affect you? How is it impacting your life? Are your difficulties causing distress?
Please feel free to tell us about anything you think might be relevant to your current or previous difficulties.

We recognise that this last section might be one of the more difficult ones to complete. We encourage you to continue with the form. The below details are really important for us to get you the help that you need right now. If you do not feel comfortable weighing yourself, please ask a professional e.g. GP, friend or family member to weigh you and complete this section of the form for you. We want to emphasise that regardless of your weight, we are here to connect you with the support you need.
29. If you experience menstruation: Over the past three-to-four months have you missed any menstrual periods?
30. Are you currently experiencing any of the following? (Select all that apply)
31. Where did hear about the service?

Please note we are not an emergency or crisis service. If you are worried about acting on suicidal thoughts and cannot keep yourself safe, please use the information below for support:

  • Newham Home Treatment Team – 0800 073 0066 (24 hrs)
  • Critical Emergency – Visit your local A&E department or contact NHS 111
  • Service Tower Hamlets Crisis Intervention – 0800 073 003 (24hrs)
  • Samaritans on 116 113
  • City & Hackney Crisis Service - 0800 073 0006 (24 hours)
  • Contact your GP Mind Crisis Cafes 01582 722 225
  • If you need immediate support to remain safe, please call 999

NHS 111, 'Option 2' in East London
You are also able to call NHS 111 and select 'Option 2' in East London. Calls to the local crisis lines currently in place at ELFT will be diverted to the centralised 111, option 2 service, meaning that no calls will be missed.

We encourage those known to services to continue contacting them in the ways they had been doing so previously during working hours. Those wishing to contact a mental health professional outside of hours – or those who aren’t previously known to services – should contact 111 and select option 2. Read more in our website news item.

Thank you
Thank you for taking the time to fill out this form. Someone from our team will be in contact with you using one of the contact methods that you provided

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East London Eating Disorder Service (Adults)

We are a community-based service providing support to adults in Newham, Tower Hamlets, and City & Hackney. We provide specialist evidence-based treatment to individuals struggling with eating disorders and disordered eating symptoms.