Name *

First Name

Last Name

GP Consent *

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

I understand

Name *

First Name

Last Name

Parental Consent

By ticking this box, I understand that SYEDA will contact my parent/carer if there are any concerns about my mental/physical wellbeing.

I understand

Do you have diabetes?

Yes

No

How long have you been experiencing food issues? *

Under 6 months

6 months - 1 year

1-2 years

2-3 years

3 years plus

Do you ever make yourself sick after eating?

Yes

No

In the past

Do you ever use laxatives?

Yes

No

In the past

Do you exercise regularly?

Yes

No

Do you ever restrict the amount of food you eat on purpose?

Yes

No

Do you worry that you have lost control over your eating?

Yes

No

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

Yes (Lost)

Yes (Gained)

No

Do you ever use exercise as a way of coping with difficult thoughts and feelings?

Yes

No

Do you believe yourself to be overweight when others say you are underweight?

Yes

No

Do you ever eat large amounts of food to help you cope with difficult thoughts and feelings?

Yes

No

Would you say that food dominates your life?

Yes

No

Have you seen your GP about your food issues?

Yes

No

Is your parent/carer aware of your food issues?

Yes

No

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

Yes

No

Have you previously received support for an eating disorder? *

Yes

No

Gender Identity

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

Yes

No

How do you identify?

Female

Male

Non-Binary

Other (please specify below)

What are your preferred pronouns?

She/Her

He/Him

They/Them

Other

Sexual Orientation

Bi

Gay/Lesbian

Hetrosexual/Straight

Prefer not to say

Other (please specify below)

Do you consider yourself to have a disability?

Yes

No

Do you have any other Mental Health difficulties or consider yourself to be neurodivergent?

Please answer this question whether you have an official diagnosis, or consider yourself to have any of the above conditions.

Yes

No

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

For example you may require a hearing loop, documents supplied in braille or a translator

Yes

No

Are you either a...

Refugee

Asylum Seeker