<p> Yorkshire Centre for Eating Disorders Newsam Centre, Seacroft Hospital Leeds, LS14 6WB E: [email protected] T. 0113 855 6400 F. 0113 855 6401</p><p>Yorkshire Centre for Eating Disorders </p><p>Referral Form</p><p>SECTION A: INFORMATION FOR REFERRERS</p><p>Services Provided and Referral Criteria</p><p>The Yorkshire Centre for Eating Disorders (YCED) in Leeds is a specialist service which provides treatment for individuals with eating disorders. We provide community, outpatient and inpatient treatments utilising a range of therapies alongside medical risk management in line with NICE and MARSIPAN (Royal College of Psychiatrists) guidelines. We accept referrals for individuals who:</p><p> Are 18 years of age or above, however, we can also accept referrals for individuals who are 17 if they are not in full time education. </p><p> Have moderate to severe Anorexia Nervosa, i.e. core psychopathology and BMI<17kg/m²</p><p> Have severe Bulimia Nervosa, i.e. core psychopathology and daily bingeing AND daily purging</p><p> Have ‘Eating Disorder Not Otherwise Specified’ (EDNOS) if they are pregnant or have type 1 Diabetes Mellitus </p><p>All referrals are discussed at our weekly MDT meeting and please be aware that referrals received after 1pm on a Tuesday may not be reviewed until the following week. YCED can offer consultation and second opinion assessments in complex cases where an eating disorder is part of a comorbid condition however we are not commissioned to offer treatment if individuals do not meet the above referral criteria. We do not accept self-referrals. We also do not accept referrals for individuals who have a current substance misuse disorder and we require a period of 6 months abstinence before we can offer any clinical input. YCED can also offer packages of training and consultancy for other UK clinicians.</p><p>Note that all individuals are welcome to attend our weekly YCED support group even if they do not meet our referral criteria. Likewise all family and carers of individuals affected by eating disorders are welcome to attend our monthly Family and Carers Support Group. For further information regarding these support groups please contact our administration team.</p><p>Care Pathways </p><p>For individuals registered with a Leeds GP: </p><p> Individuals with a BMI<15kg/m² can be referred directly to YCED from primary care.</p><p> All other individuals should be referred via the Single Point of Access (0300 300 1485) for screening by secondary mental health services and a holistic and FACE risk assessment must be provided before YCED can accept the referral.</p><p>For individuals registered with a GP outside of the Leeds catchment area:</p><p>1  All individuals require a named care coordinator from their local community mental health team to ensure that coordinated care between YCED and local services is optimised in keeping with the Care Programme Approach. </p><p> All referrals for patients outside the Yorkshire region should be made via NHS England. </p><p>For individuals currently under the care of Leeds Teachings Hospitals NHS Trust (LTHT): </p><p> All LTHT inpatient referrals should be made via LTHT Liaison Psychiatry services who can then refer to YCED if needed. </p><p> All LTHT outpatient referrals should be made as per the standard care pathway outlined above.</p><p>B: YCED REFERRAL FORM</p><p>Please complete all sections electronically. YCED cannot accept referrals unless all the relevant information is provided below. Once completed please email to: [email protected]. </p><p>Please also send copies of:</p><p> any recent clinical assessment letters  a recent risk assessment  most recent blood results  most recent ECG</p><p>DATE OF REFERRAL</p><p>AREA (Leeds/National)</p><p>REFERRER DETAILS</p><p>Name</p><p>Profession</p><p>Work address</p><p>Contact telephone number</p><p>Email address</p><p>Fax number</p><p>CARE COORDINATOR DETAILS (if applicable, see section A)</p><p>Note: YCED cannot accept referrals for national patients without a named care coordinator</p><p>Yes No Care coordinator applicable</p><p>If applicable, is the care coordinator also the </p><p>2 referrer? If no, then please complete the box below.</p><p>CARE COORDINATOR DETAILS:</p><p>Name</p><p>Profession</p><p>Work address</p><p>Contact telephone number</p><p>Email address</p><p>Fax number</p><p>REASON FOR REFERRAL</p><p>Yes No Assessment and community/outpatient treatment</p><p>Inpatient treatment</p><p>Second opinion assessment</p><p>Other (please specify)</p><p>PATIENT DETAILS</p><p>Name</p><p>Gender</p><p>DOB</p><p>Home address</p><p>NHS number</p><p>Contact telephone number</p><p>Next of kin</p><p>Ethnicity</p><p>Interpreter required</p><p>Patients opinion of referral to YCED (please delete Aware and consents to referral as appropriate) Aware but does not consent to referral Not aware of referral Other (please specify)</p><p>3 GP DETAILS</p><p>Name</p><p>Work address</p><p>Contact telephone number</p><p>Email address</p><p>Fax number</p><p>CLINICAL DETAILS</p><p>Summary of current difficulties</p><p>Background history including previous ED treatment</p><p>MHA status</p><p>BMI</p><p>Weight (kg)</p><p>Height (m)</p><p>BMI (wt/ht2)</p><p>Behaviours </p><p>Yes No Type Frequency Bingeing …times/day …times/week</p><p>Self-induced …times/day vomiting ….times/week</p><p>Laxative misuse …tablets/day …tablets/week</p><p>4 Diuretic misuse …tablets/day …tablets/week</p><p>Excessive exercise …hours/day …hours/week</p><p>Alcohol misuse …units/week</p><p>Illicit drug use …/day …/week</p><p>…/day …/week</p><p>Other disordered …/day eating behaviours …/week (please specify)</p><p>Risk summary</p><p>History Current Details Ideas of self-harm</p><p>Ideas of harming others Deliberate self-harm (without suicidal intent)</p><p>Suicide attempts</p><p>Plans/preparations to commit suicide Physical harm to others</p><p>Threats/intimidation (including verbal abuse)</p><p>Child protection issues</p><p>Safeguarding issues</p><p>Absconding</p><p>Compulsory admission</p><p>Physical comorbidities (please list)</p><p>5 Psychiatric comorbidities (please list)</p><p>Current medication (please list and include dosages)</p><p>Allergies (please list and give details)</p><p>Food intolerances (please list and give details if medically confirmed)</p><p>Dietary requirements </p><p>Yes No Details None</p><p>Vegan</p><p>Vegetarian</p><p>Other (please specify)</p><p>Date and summary of most recent blood investigations (please attach or send formal results with this referral form) </p><p>Date Summary</p><p>Date and summary of most recent ECG (please attach or send ECG with this referral form)</p><p>Date Summary</p><p>Additional information</p><p>6 7</p>