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Centre for Psychotherapy
Hunter New England Local Health Network
ABN 24 500 842 605
72 Watt Street, NEWCASTLE NSW 2300
PO Box 833, NEWCASTLE NSW 2300
Tel 02 4924 6820 Fax 02 4924 6801
Website www.hnehealth.nsw.gov.au
EATING DISORDERS REFERRAL FORM - CENTRE FOR PSYCHOTHERAPY (CfP)
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Referrals will be accepted from GPs or other health care professionals. Please contact CfP if you would
like to discuss this referral on 4924 6820.
CfP provides treatment for clients who meet full criteria for Anorexia Nervosa (AN), Bulimia Nervosa (BN)
and Other Specified Eating Disorder (eg: atypical AN or BN) where the duration of illness has been
longer than 3 years and/or the client has participated in previous treatment (for more detail please see
inclusion and exclusion criteria at the end of the referral form)
Allocation for treatment may take several months due to demand
PATIENT/CLIENT DETAILS
Name
Address
Telephone/ Mobile
Date of Birth
REFERRER DETAILS
Name
Designation
Address
Telephone/ Fax
*THE FOLLOWING INFORMATION IS ESSENTIAL TO PROCESS THIS REFERRAL*
GP DETAILS (IF NOT REFERRER)
Name
Address
Telephone/ Fax
Client Experiences:
Y/N
Duration of
symptoms (ie:
no. of mth/ yrs)
Frequency of
symptoms( ie:
no.of times/ wk)
Restrictive eating (persistent restriction of
energy intake below requirements)
Binge Eating (larger amount of food than normal
+ loss of control over eating)
Vomiting (self induced)
Laxative Abuse
Excessive Exercise (exercising in a driven way
for the purpose of weight loss)
BMI (kg/htm2):
Weight (kg):
Total Weight Lost/ Gain:
Over what time frame (weeks/mths):
Is weight Loss Still Occurring? Y / N
If yes, at what rate per week?
(Updated 0ctober 2013)
Height (m):
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Centre for Psychotherapy
Hunter New England Local Health Network
ABN 24 500 842 605
72 Watt Street, NEWCASTLE NSW 2300
PO Box 833, NEWCASTLE NSW 2300
Tel 02 4924 6820 Fax 02 4924 6801
Website www.hnehealth.nsw.gov.au
THE CLINICAL PROBLEM (EATING AND OTHER ISSUES)
Please include clinician’s evaluation, client’s perspective and motivation for treatment and clients’ family/social
supports. Please also note any co-morbidity eg; Borderline Personality Disorder or Bipolar Disorder.
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CURRENT TREATMENT (INCLUDING MEDICATION, CURRENT THERAPY AND OTHER AGENCIES AND
THERAPISTS WHO ARE DIRECTLY INVOLVED)
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PAST TREATMENT (INCLUDING OUTCOME)
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HOSPITALISATION/ DAY PROGRAM (DATE, LENGTH OF STAY AND OUTCOME)
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COMPLICATING FACTORS (LEGAL MATTERS, TRANSPORT & ACCESS PROBLEMS, SUBSTANCE ABUSE,
DELIBERATE SELF HARM, MEDICAL HISTORY EG: DIABETES, PREGNANCY)
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(Updated 0ctober 2013)
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Centre for Psychotherapy
Hunter New England Local Health Network
ABN 24 500 842 605
72 Watt Street, NEWCASTLE NSW 2300
PO Box 833, NEWCASTLE NSW 2300
Tel 02 4924 6820 Fax 02 4924 6801
Website www.hnehealth.nsw.gov.au
MEDICAL INFORMATION (PLEASE INDICATE IF WITHIN ACCEPTABLE RANGE AS CFP STAFF ARE NOT IN A
POSITION TO INTERPRET PATHOLOGY RESULTS)
YES
NO
YES
Dehydration
Blood pressure
Iron Status
B12
Heart Rate
Temperature
Folate
ECG (when clinically indicated Or BMI<14)
Electrolytes
Phosphate (when clinically indicated)
Renal function
Liver function
Magnesium (when clinically indicated)
Bone Densitometry (if amenorrhoea> 6 months
NO
PLEASE FAX REFERRAL TO MENTAL HEALTH CONTACT CENTRE ON
FAX: 02 6767 8739
CENTRE FOR PSYCHOTHERAPY ELIGIBILITY CRITERIA
INCLUSION CRITERIA
EXCLUSION CRITERIA

Over 18yrs

BMI<14
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Meets DSM V criteria for Anorexia Nervosa

Binge Eating Disorder
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Meets DSM V criteria for Bulimia Nervosa
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Obesity
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Has a BMI ≥14 *
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Other Specified Eating Disorders will be considered under the
following guidelines:
Feeding and Other Specified Eating
Disorders eg: Rumination Disorder,
Night Eating Disorder, Purging
Disorder and Avoidant/restrictive
Food Intake Disorder (DSM V)


Atypical AN or BN

Client has participated in at least 1 prior treatment

The duration of illness is greater than 3 years
*
Client must be willing to consider entering an eating disorder
treatment program
* For clients with a BMI below 14, psychotherapy is often contraindicated for these clietns an assessment
session may be offered to determine if psychotherapy is a viable treatment option.
Considerations will include:
 client’s ability to engage in and benefit from psychotherapy
 client’s medical stability as intensive inpatient treatment may be more appropriate
 complexity of client’s presentation and co-morbidity
 Client’s readiness for change
(Updated 0ctober 2013)
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Centre for Psychotherapy
Hunter New England Local Health Network
ABN 24 500 842 605
72 Watt Street, NEWCASTLE NSW 2300
PO Box 833, NEWCASTLE NSW 2300
Tel 02 4924 6820 Fax 02 4924 6801
Website www.hnehealth.nsw.gov.au
DSMV DIAGNOSTIC CRITERIA
ANOREXIA NERVOSA
RESTRICTING TYPE:
BINGE EATING/
PURGING TYPE:
BULIMIA NERVOSA
OTHER SPECIFIED
EATING
DISORDER
A. Restriction of energy intake relative to requirements leading to a significantly
low body weight in the context of age, sex, developmental trajectory, and physical
health. Significantly low weight is defined as a weight that is less than minimally
normal, or, for children and adolescents, less than that minimally expected
B. Intense fear of gaining weight or becoming fat or persistent behavior that interferes
with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one's body weight or shape is experienced, undue
influence of body weight or shape on self-evaluation, or persistent lack of
recognition of the seriousness of the current low body weight.
During the last three months, the person has not engaged in recurrent episodes of
binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives,
diuretics, or enemas). This subtype describes presentations in which weight loss is
accomplished primarily through dieting, fasting, and/or excessive exercise.
During the last three months, the person has engaged in recurrent episodes of binge
eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives,
diuretics, or enemas)
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by
both of the following:
(1) Eating, in a discrete period of time (for example, within any 2-hour period), an
amount of food that is definitely larger than most people would eat during a similar
period of time under similar circumstances.
(2) A sense of lack of control over eating during the episode (for example, a feeling
that one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain,
such as self-induced vomiting; misuse of laxatives, diuretics, or other medications,
fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on
average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Atypical Anorexia Nervosa: All of the criteria for Anorexia Nervosa are met, except
that, despite significant weight loss, the individual’s weight is within or above the
normal range.
Atypical Bulimia Nervosa: All of the criteria for Bulimia Nervosa are met, except that
the binge eating and inappropriate compensatory behaviors occur, on average,
less than once a week and/or for less than for 3 months.
TO BE COMPLETED BY CENTRE FOR PSYCHOTHERAPY STAFF
Date Received: ____________________
CfP Staff Member on Intake:
Sufficient info provided to take to intake meeting? Yes / No
________________________
If no, referrer contacted for further info? Yes / No
Comment:
_________________________________________________________________________________________
_________________________________________________________________________________________
Outcome from intake meeting:
_________________________________________________________________________________________
(Updated 0ctober 2013)
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