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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) 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): 1/4 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. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ CURRENT TREATMENT (INCLUDING MEDICATION, CURRENT THERAPY AND OTHER AGENCIES AND THERAPISTS WHO ARE DIRECTLY INVOLVED) ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ PAST TREATMENT (INCLUDING OUTCOME) ___________________________________________________________________________________________ ___________________________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ HOSPITALISATION/ DAY PROGRAM (DATE, LENGTH OF STAY AND OUTCOME) ___________________________________________________________________________________________ ___________________________________________________________________________________________ COMPLICATING FACTORS (LEGAL MATTERS, TRANSPORT & ACCESS PROBLEMS, SUBSTANCE ABUSE, DELIBERATE SELF HARM, MEDICAL HISTORY EG: DIABETES, PREGNANCY) ___________________________________________________________________________________________ ___________________________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ (Updated 0ctober 2013) 2/4 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 Meets DSM V criteria for Anorexia Nervosa Binge Eating Disorder Meets DSM V criteria for Bulimia Nervosa Obesity Has a BMI ≥14 * 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) 3/4 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) 4/4