ARFID referral

SYEDA takes a family-led approach to supporting people with ARFID. If you are completing this referral on behalf of your child or a loved one, please complete the Family & Friends Referral instead of this form.

Once we receive your Family & Friends Referral, we will arrange an assessment. If appropriate, you will be asked to complete our "Not Just a Fussy Eater" ARFID Family & Friends course before your loved one is offered any further support.

Our support for those who experience an ARFID presentation will usually be in a group setting and is available to anyone from 11 up to the age of 25.*

I confirm that I am aged between 11 - 25 years

Our referral criteria

We are unable to offer direct support to clients who:

Are at a severely low weight (BMI 17.5 or below) - in this case you need to visit your GP for a referral to Sheffield Eating Disorders Service
Are purging (self induced vomiting/laxative abuse) 5 times per week or more. - in this case you need to visit your GP for a referral to Sheffield Eating Disorders Service
Are excessively abusing alcohol/substances
Are experiencing severe mental health difficulties (Referrals would need to be assessed on a case-by-case basis, to determine the suitability for accessing Eating Disorder treatment).
Have attempted to take their own life within the last 6 months, or are engaging in serious self-harm/risk taking behaviours.
Have received bariatric surgery within the last 6 weeks, or if they are still unable to eat a minimum of 3 solid meals per day. You must also be accessing your GP for monitoring and taking the recommended vitamins and minerals.
If it is determined at triage that the client would require more specialised support.
Do not have a GP registered in Sheffield, Barnsley, Rotherham or Doncaster.

Referral criteria*

I confirm that I meet the referral criteria

I'm not sure if I meet the criteria

If you are unsure about any of the referral criteria please contact us to discuss this further.

Name*

First

Last

Address 1*

Address 2

Town / city*

Postcode*

Contact number*

Please provide a number that you're happy for a message to be left on. Be aware that we may need to call you to discuss your referral and we will call you to arrange your assessment.

Email address*

Date of birth*

DD/MM/YYYY

NHS number

If you are unsure of your NHS number you can request this from your GP or by visiting www.nhs.uk/nhs-services/online-services/find-nhs-number

What is the name of your GP and the address of your GP practice?*

GP Consent*

By ticking this box I understand that SYEDA will contact my GP if there are any serious concerns around physical or mental wellbeing.

I understand

Are you pregnant or have you recently given birth?

Yes

Do you have diabetes?

Yes

What is your height and weight?*

We cannot process your referral without this information

Have you lost or gained weight in the past 6 months?

I have lost weight

I have gained weight

Neither

How much weight you have lost/gained?

Do you have difficulties with eating - involving avoidance or restriction of certain foods or of overall amount eaten – that are NOT explained by a diagnosed medical condition?*

Select an option

Are your eating habits related to you thinking that you are too big or too heavy?

Select an option

Over the past 3 months, has your eating led to difficulty maintaining a healthy weight, or if you are still growing, difficulty gaining enough weight to grow as expected?

Select an option

Do you have any nutritional deficiencies or inadequacies as a result of limited eating (e.g. low iron, low vitamin B12, low vitamin C)?

Select an option

Do you depend on tube feeding or nutritional supplements to maintain your nutrition, weight or growth (i.e without these you would have nutritional deficiencies or lose weight)?

Select an option

Does your eating have a negative effect on your day to day life or your ability to participate in a full range of age-appropriate activities?

Select an option

Does your eating have a negative effect on your family/partner relationships or other aspects of your family life (e.g. going out together, on holiday, etc.)?

Select an option

Have you seen your GP about your food issues?

Yes

Are you currently receiving any support from other services i.e CMHT, CAMHS etc for an eating disorder or other difficulties?*

Yes

What support are your receiving and where from?

Are you currently receiving or have you previously received dietetic input?*

Yes

Please could you give an overview of the advice that you recevied from them.

Have you previously received support for ARFID?*

Yes

What support have you received and where from?

Please could you provide as much information as possible about your behaviours relating to eating difficulties and the support you feel you need*

Please could you list the foods that you regularly eat as part of your diet.

Please list any nutritional supplements, or prescribed medication from your GP for your diet?

If you are under the age of 18, has another person completed this form on your behalf?

This could be a parent, carer or a professional

Yes

Who would you like us to contact to discuss your referral?

Myself (details as above)

Someone else

Please confirm their details below:

This should include their name, relationship to you, their contact number and email address.

SYEDA Equalties And Diversity Monitoring

It is essential that our services are provided fairly and that they reach the people who need to use them. The monitoring information we collect is vital to this process. It helps us understand who is using are services and who is not, having this information helps us improve services and reduce barriers to access. The information we collect will always be kept confidential and secure. If you do not wish to answer a question you can leave it blank. These questions below will take you around 2 minutes to complete. Thank you.

I would describe my ethnicity as:

Select an option

Please specify your ethnicity here

Is the gender you identify with the same as your sex registered at birth?

Yes

How do you identify?

Female

Male

Non-binary

Other

Please specify your gender identity

What are your preferred pronouns?

She/Her

He/Him

They/Them

Other

Please specify your preferred pronouns

Please specify your sexual orientation

Disability

A disability is an impairment that has (or is likely to have) a substantial (more than minor), adverse, long-term (more than a year) effect on the ability to carry out normal day-to-day activities.

Do you consider yourself to have a disability?

Yes

If you answered yes to the above, plese could you give further details (including any support received/receiving)?

Do you have any other Mental Health or Psychological difficulties?

Yes

If you answered yes to the above, plese could you give further details (including any support received/receiving)?

Do you have any additional accessibility needs that you feel we should be aware of?

Yes

If you answered yes to the above, plese could you give further details (including any support received/receiving)?

Thank you very much for taking the time to complete this section. Your input is very important to us.

Are you human?*

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ARFID referral

Make a referral for ARFID support

Our referral criteria

SYEDA Equalties And Diversity Monitoring

Disability