Patient Referral Form

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Peterborough & Cambridgeshire Eating Disorder Referrals

Our charity works as part of a collaborative pathway with the local NHS eating disorder team and if your symptoms meet the criteria for the secondary care eating disorder team (CPFT Adult Eating Disorder Service) we will, with your consent refer you on to them and let your GP know.

We can accept referrals from individuals in the Peterborough and Cambridgeshire area only.

Current waiting time: 4-6 weeks for routine assessments and 2-3 weeks for priority assessments.

Mental Health Crisis or in need of Urgent Care.

PEDS does not provide a service for those in a mental health crisis or in need of urgent care. We are not able to accept referrals if the individual is currently experiencing suicidal thoughts/plans or has been actively suicidal in the past 12 weeks.

In this case, we would recommend the individual seeks support initially for their low mood and self-harm risks via their GP, First Response Team via phoning 111 option 2 (if within Cambridgeshire) or A&E.

There is also the HEAR text service via Texting HEAR to 85258.

Referrals information

Please be advised that PEDS is accepting new referrals for all ages, including children and young people.

Please note that we recommend anyone referring themselves to us to also make an appointment with their GP for a health check.

Please note: Referrals are processed Monday – Friday, 9:00 – 16:00 and will be triaged within 7 days.

Are You Referring(Required)

On Behalf of Someone Else

Yourself

Has the Person You Are Referring Given Their Consent?

Yes

Referrer Name(Required)

Referrer Email Address(Required)

Referrer Telephone Number(Required)

What Is Your Relationship to the Person Being Referred?(Required)

Patient Full Name(Required)

Patient NHS Number: if known(Required)

Patient Date of Birth(Required)

To ensure we address the patient correctly, please let us know their preferred pronouns(Required)

Which of the following best describes the patient?(Required)

Female

Male

Non-binary

Transgender

Prefer not to say

Other

Is the patient's gender the same as at birth?(Required)

Yes

Prefer not to say

Unable to answer

Other

Patient Email Address(Required)

For children and young people who don't have an email address please click here

Patient doesn't have an email address

Patient telephone Number(Required)

Patient Address(Required)

Street Address Address Line 2 City County Post Code

What is the your ethnicity?(Required)

White (including White British, White Irish, White Gypsy or Irish Traveller, or any other White background)

Black, African, Caribbean or Black British

Mixed or Multiple ethnicity (including White and Black Caribbean, White and Black African, White and Asian, or any other Mixed or Multiple ethnic background)

Asian or Asian British (including Indian, Pakistani, Bangladeshi, Chinese or any other Asian background)

Other ethnic group

Prefer not to say

Do you have a neurodivergent diagnosis? (such as Autism/ADHD etc)(Required)

Yes

Awaiting diagnosis

Prefer not to say

If yes, please select: (tick all that apply)(Required)

Autism

ADHD

Dyslexia

Dyspraxia / DCD

Other (please specify)

If you are awaiting a diagnosis, please tell us when you were referred

If you are awaiting a diagnosis, please tell us where you were referred to:

Are you currently receiving any treatment or taking any medication related to your neurodivergence(Required)

Yes

Do you have an Autism or ADHD Passport that you would like us to be aware of?(Required)

Yes

Please share key information:

Anything else you would like us to know to help support you?

Is the patient a student?(Required)

Yes

Name of School / College / University

If Cambridge University, which college?

What course is being studied ?

Year of study ?

If university, Postgraduate or Undergraduate?

Are you employed?(Required)

Yes

What is the occupation?

Next of Kin details

Next of Kin Name(Required)

Relationship(Required)

Phone(Required)

Email(Required)

Patient Information

Height (M)(Required)

Height is required. Please enter as numbers (e.g. 1.7m). We can’t move forward with your referral unless this field is completed.

Current Weight (KG)(Required)

Weight is required. Please enter as numbers (e.g. 70kg). We can’t move forward with your referral unless this field is completed.

Please detail any weight history(Required)

Brief Description of Your Current Eating Disorder / At Risk of Eating Disorder Symptoms(Required)

Have You Received Any Help From Eating Disorder / Mental Health Services in the Past?(Required)

Yes

Please provide more information(Required)

Are you currently open to any services or on any waiting lists?(Required)

Yes

Please provide more information(Required)

Services such as Centre 33, Talking Therapies etc

Do You Experience Bingeing?(Required)

Yes

How many times per week(Required)

How long have you been experiencing binge eating symptoms for - please detail in weeks, months or years(Required)

During your episodes of excessive overeating, how often did you feel like you had no control over your eating (e.g., not being able to stop eating, feel compelled to eat, or going back and forth for more food)?(Required)

Never or Rarely

Sometimes

Often

Always

During your episodes of excessive overeating, how often did you continue eating even though you were not hungry?(Required)

Never or Rarely

Sometimes

Often

Always

During your episodes of excessive overeating, how often were you embarrassed by how much you ate?(Required)

Never or Rarely

Sometimes

Often

Always

During your episodes of excessive overeating, how often did you feel disgusted with yourself or guilty afterward?(Required)

Never or Rarely

Sometimes

Often

Always

During the last three months how often did you make your self vomit as part of your eating disorder thinking?(Required)

Never or Rarely

Sometimes

Often

Always

Do you experience self induced vomiting as a symptom of your eating disorder presentation(Required)

Yes

How often each day/week/month(Required)

How long has this symptom been part of your eating disorder - weeks/months/years(Required)

Do You Use Laxatives, Diuretics, or Slimming Pills or any other weight controlling medication prescribed or unprescribed?(Required)

Yes

What do you use?(Required)

How many times per week?(Required)

Do You Restrict Your Eating?(Required)

Yes

How many times per week(Required)

How many weeks, month or years(Required)

Are You on Any Medication?(Required)

Yes

Please Provide Details(Required)

Do you have type 1 diabetes?(Required)

Yes

Are you pregnant?(Required)

Yes

GP Name(Required)

GP Address(Required)

Street Address Address Line 2 City County Post Code

I agree to my health record at this service being shared with other healthcare providers involved in my care — such as GPs, secondary care services, and community organisations. We may also contact your GP to notify them of your referral and arrange a baseline health check(Required)

Yes

I would like this service to be able to view information in my health record that has been recorded by other healthcare services - such as GPs, secondary care departments, community organisations etc.(Required)

Yes

I give consent for you to liaise with the Adult Eating Disorder Team if required(Required)

Yes

I give consent for you to liaise with CAMHS / CAMHS Eating Disorder Team if required(Required)

Yes

I give consent for you to liaise with the University / School / College Wellbeing Team if required(Required)

Yes

I give consent for you to speak with my next of kin/carer/loved one if required(Required)

Yes

I give PEDS consent to contact me by (Please Tick At Least One)(Required)

Phone

Post

SMS

Where did you hear about PEDS?(Required)

Registered Charity Number: 1156578
Tel: 01733 300 290
Email: admin@pedsupport.co.uk

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