First Steps ED Referral Form

1
Unique ID
2
Who is making this referral?* This field is required.
I am referring myself
I am a professional referring on behalf of another
I am a carer referring on behalf of another
I am a carer referring myself for carer support
3
If you are completing this referral for someone else, are they aware that a referral to First Steps ED is being made?* This field is required.
YESNO
4
Have you accessed First Steps ED before?* This field is required.
Yes
No
Unsure
5
Has the individual accessed First Steps ED before?* This field is required.
Yes
No
Unsure
6
Please provide a brief description of any eating difficulties that you may be experiencing at the moment. * This field is required.
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Large
Normal
Small
Ok
Ok
7
Please provide a brief description of any eating difficulties the individual may be experiencing at the moment. * This field is required.
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Large
Normal
Small
Ok
Ok
8
Do you have any other mental health difficulties?Please tick as appropriate.
Anxiety
Attention Deficit Hyperactivity Disorder (ADHD)
Autism Spectrum Disorder (ASD)
Bi-polar Disorder
Depression
Obsessive-Compulsive Disorder (OCD)
Personality Disorder
Post-Traumatic Stress Disorder (PTSD)
Other
9
Do they have any other mental health difficulties?Please tick as appropriate.
Anxiety
Depression
Bi-polar Disorder
Obsessive-Compulsive Disorder (OCD)
Personality Disorder
Post-Traumatic Stress Disorder (PTSD)
Autism Spectrum Disorder (ASD)
Attention Deficit Hyperactivity Disorder (ADHD)
Other
10
Are you currently receiving any professional support?Please tick as appropriate.
Community Mental Health Team (CMHT)
Child and Adolescent Mental Health Services (CAMHS)
Child and Adolescent Mental Health Services - Eating Disorders (CAMHS ED)
Adult Eating Disorder Service
Drug and Alcohol Services
Crisis Team
IAPT - Talking Therapy
Other
11
Are they currently receiving any professional support?Please tick as appropriate.
Community Mental Health Team (CMHT)
Child and Adolescent Mental Health Services (CAMHS)
Child and Adolescent Mental Health Services - Eating Disorders (CAMHS ED)
Adult Eating Disorder Service
Drug and Alcohol Services
Crisis Team
IAPT - Talking Therapy
Other
12
What is your name?* This field is required.
First Name
Last Name
13
What is your date of birth?* This field is required.
Date
Day
Month
Year
14
What is your address?* This field is required.
House Number/Name
Street
Town/City
County
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Please provide your contact details.* This field is required.Please provide the contact details with which you wish to be directly contacted on. This may include leaving a voicemail or a text.
Please enter a number
Please enter your email
16
Please state which organisation you are referring from.* This field is required.
Please Select
Please Select
VitaMinds IAPT
Trent PTS
Insight IAPT
P3 Charity
CAMHS
CAMHS ED
Community Mental Health Team
Education
GP
Housing
IAPT Provider
Local Authority
Pediatrics
School Nurse
Third Sector
University Wellbeing Team/Specialist Mentor
Other
Please state which organisation you are referring from.
Please state which organisation you are referring from. (Other)
17
Please state your relationship to the individual being referred.* This field is required.
Please Select
Please Select
Parent
Carer
Sibling
Grandparent
Family friend
Please state your relationship to the individual being referred.
Please state your relationship to the individual being referred.(Other)
18
Please provide your emergency contact details.* This field is required.Why do we need this? In order to access our services, we need to be provided with an emergency contact who we are able to get in touch with in the case of an emergency. Please note that your emergency contact will not be notified of your submitted referral and ongoing support.
Their name
Their relationship to you
Their contact number
19
What is your education/employment status?* This field is required.
Education
Part-time employment
Full-time employment
Unemployed
Unemployed (disability)
Carer
Prefer not to say
Other
20
What stage of education are you in?
Primary School
Secondary School
College/Sixth Form
University
21
Which university or college do you attend?
University of Nottingham
Nottingham Trent University
Loughborough University
University of Derby
University of Leicester
De Montfort University
Derby College
Nottingham College
Buxton College
Chesterfield College
Other
22
What is your GP practice?* This field is required.Please choose from the drop-down list. If your surgery is not included, please give details in the box below.
Please provide name of GP practice
23
Do you consider yourself to have disability/mobility issues?* This field is required.
Yes
No
Unsure
24
Would you need any adjustments made to attend an initial assessment?E.g. wheelchair access, downstairs room, large print
Huge
Large
Normal
Small
Ok
Ok
25
What is your gender?* This field is required.
26
Is the gender you identify with the same as your sex assigned at birth?
YESNO
27
What is your gender identity?
28
What is your gender identity?* This field is required.
Male
Female
Transgender Male
Transgender Female
Intersex
Non-binary
Gender questioning
Prefer not to say
Not listed
29
What is your religion/religious denomination?* This field is required.
Christianity
Islam
Sikhism
Judaism
Hinduism
Buddhism
Janism
Taoism
No religion
Prefer not to say
Unsure
Other
30
What is your sexual orientation?* This field is required.
Straight/Heterosexual
Bisexual
Gay/Homosexual
Prefer not to say
Unsure
Other
31
What is your nationality/ethnic origin?* This field is required.
Arab
Asian / Asian British- Indian
Asian / Asian British- Pakistani
Asian / Asian British- Bangladeshi
Asian / Asian British- Chinese
Asian / Asian British- Any other Asian background
Black / African / Caribbean / Black British- African
Black / African / Caribbean / Black British- Caribbean
Black / African / Caribbean / Black British- Any other Black / African / Caribbean background
Mixed / Multiple ethnic groups- White and Black Caribbean
Mixed / Multiple ethnic groups- White and Black African
Mixed / Multiple ethnic groups- White and Asian
Mixed / Multiple ethnic groups- Any other Mixed / Multiple ethnic background
White- English / Welsh / Scottish / Northern Irish / British
White- Irish
White- Gypsy or Irish Traveller
White- Any other White background
Any other ethnic groups
Prefer not to say
Unsure
Other
32
Where did you hear about First Steps ED?* This field is required.
GP
Counsellor/Therapist
Online search
Social media
Friend/Family member
NHS professional
School professional
Other
33
What is their name?* This field is required.
First Name
Last Name
34
What is their date of birth?* This field is required.
Date
Day
Month
Year
35
What is their address?* This field is required.
House Number/Name
Street
Town/City
County
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
36
Please provide their contact details.* This field is required.Please note that we will use the contact details provided to contact the individual directly. This may include leaving a voicemail or a text.
Please enter their number
Please enter their email
37
Please provide their emergency contact details.* This field is required.
Name
Relationship to individual
Contact number
38
If this referral is for someone under the age of 18, who should we contact to arrange support?* This field is required.Depending on the age of the young person and the involvement of other adults in their support, it is not always appropriate for us to contact the young person directly. Please indicate who we should call/email to make initial contact.
The young person being referred
The parent/carer listed as the emergency contact
Not applicable - The person being referred is aged 18 or over.
39
What is their education/employment status?* This field is required.
Education
Part-time employment
Full-time employment
Unemployed
Unemployed (disability)
Carer
Prefer not to say
Other
40
What stage of education are they in?* This field is required.
Primary school
Secondary school
College/Sixth Form
University
41
Which university do they attend?* This field is required.
University of Nottingham
Nottingham Trent University
Loughborough University
University of Derby
University of Leicester
De Montfort University
Other
42
What is their GP practice?* This field is required.
Please provide name of GP practice
43
Do they consider themselves to have a disability/mobility issues?* This field is required.
Yes
No
Unsure
44
Do they need any adjustments made to attend an initial assessment?E.g. wheelchair access, downstairs room, large print
Huge
Large
Normal
Small
Ok
Ok
45
What is the gender identity of the individual you are referring? * This field is required.
Male
Female
Transgender Male
Transgender Female
Intersex
Non-binary
Gender questioning
Prefer not to say
Not listed
Unsure
46
What is their religion/religious denomination?* This field is required.
Christianity
Islam
Sikhism
Judaism
Hinduism
Buddhism
Janism
Taoism
No religion
Prefer not to say
Unsure
Other
47
What is their sexual orientation?* This field is required.
Straight/Heterosexual
Bisexual
Gay/Homosexual
Prefer not to say
Unsure
Other
48
What is their nationality/ethnic origin?* This field is required.
Arab
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Any other background
Mixed/Multiple Ethnic Group - White and Black African
Mixed/Multiple Ethnic Group - White and Black Asian
Mixed/Multiple Ethnic Group - White and Black Caribbean
White - British/Northern Irish/Scottish/Welsh/English
White - Irish
White - Gypsy/Irish Traveller
White - Any other background
Any other ethnic groups
Prefer not to say
Unsure
Other
49
Where did you hear about First Steps ED?* This field is required.
GP
Counsellor/Therapist
Online search
Social media
Friend/Family member
TellMi
Other
50
Is the person who is wanting support aged between 18-24* This field is required.FREED will only accept referrals who are in this age range.
YESNO
51
Have you been struggling with your eating difficulty for 3 years or less?* This field is required.
YESNO
52
Have you been to the GP regarding your eating difficulties?* This field is required.If you have not been to the GP prior to this referral, we will require you to make an appointment before the initial assessment is booked in.
YESNO
53
Do you live in High Peak District, Derby City, Derbyshire Dales or Chesterfield?* This field is required.We can only accept referrals into FREED if you live in any of the areas above
YESNO
54
Is your BMI 16.9 or lower?* This field is required.
YESNO
55
Do you live in another area of Derbyshire not listed above?* This field is required.
YESNO
56
NHS FREED Referral* This field is required.Thank you for your referral to First Steps ED. We are part of NHS Derbyshire Eating Disorders and your referral is eligible to be transferred to the NHS Adult team to access the FREED service. If you provide consent, you will be contacted by our NHS clinical partners.
I agree to this referral being forwarded to FREED
57
Privacy Statement* This field is required.By submitting this referral, you consent to us contacting the individual directly and collecting and processing the information that you have provided on our systems.
58
Referral Submission

Thank you for providing the information for our referral form.

PLEASE PRESS SUBMIT AT THE BOTTOM

What happens now?

We will contact the individual directly regarding booking in their initial assessment.

We are experiencing a high number of referrals and working to follow up within 10 working days. Please bear with us as sometimes this may take a little longer.

Our assessments are currently being completed via video clinic.

Please note:

If you have agreed to the referral being forwarded to NHS FREED, they will be in contact with the individual being referred. First Steps ED will not be in contact with any NHS FREED referrals.

For any queries, please do not hesitate to get in contact with us at info@firststepsed.co.uk or give us a call on 0300 1021685.
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