First Steps ED Referral Form

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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
Have you accessed First Steps ED before?* This field is required.
Yes
No
Unsure
4
Has the individual accessed First Steps ED before?
Yes
No
Unsure
5
Please provide a brief description of any eating difficulties that you may be experiencing at the moment. * This field is required.
Huge
Large
Normal
Small
Ok
Ok
6
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
7
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)
8
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)
9
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
10
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
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What is your name?* This field is required.
First Name
Last Name
12
What is your date of birth?* This field is required.
Date
Day
Month
Year
13
What is your address?* This field is required.
House Number/Name
Street
Town/City
County
Post Code
Please Select
Please Select
United States
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
Curacao
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
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
14
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
15
Please state which organisation you are referring from.* This field is required.
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)
16
Please state your relationship to the individual being referred.* This field is required.
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)
17
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
18
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
19
What stage of education are you in?
Primary School
Secondary School
College/Sixth Form
University
20
Which university do you attend?
University of Nottingham
Nottingham Trent University
Loughborough University
University of Derby
University of Leicester
De Montfort University
21
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
22
Do you consider yourself to have disability/mobility issues?* This field is required.
Yes
No
Unsure
23
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
24
What is your gender?* This field is required.
Female
Male
Non-binary
Transgender
25
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
26
What is your sexual orientation?* This field is required.
Straight/Heterosexual
Bisexual
Gay/Homosexual
Prefer not to say
Unsure
27
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
28
Where did you hear about First Steps ED?* This field is required.
GP
Counsellor/Therapist
Online search
Social media
Friend/Family member
29
Privacy Statement* This field is required.By submitting your referral, you consent to us contacting you directly and collecting and processing the information that you have provided on our systems.
30
Referral Submission

Thank you for completing our referral form.

PLEASE PRESS SUBMIT AT THE BOTTOM

What happens now?

You will be contacted within the next 5 working days to book in an initial assessment with a member of our team. Our assessments are currently being completed via video clinic.

For any queries, please do not hesitate to get in contact with us at info@firststepsed.co.uk or give us a call on 01332 367571.
31
What is their name?* This field is required.
First Name
Last Name
32
What is their date of birth?* This field is required.
Date
Day
Month
Year
33
What is their address?* This field is required.
House Number/Name
Street
Town/City
County
Post Code
Please Select
Please Select
United States
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
Curacao
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
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
34
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
35
Please provide their emergency contact details.* This field is required.
Name
Relationship to individual
Contact number
36
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
37
What stage of education are they in?* This field is required.
Primary school
Secondary school
College/Sixth Form
University
38
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
39
What is their GP practice?* This field is required.
Please provide name of GP practice
40
Do they consider themselves to have a disability/mobility issues?* This field is required.
Yes
No
Unsure
41
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
42
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
43
What is their sexual orientation?* This field is required.
Straight/Heterosexual
Bisexual
Gay/Homosexual
Prefer not to say
Unsure
44
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
45
Where did you hear about First Steps ED?* This field is required.
GP
Counsellor/Therapist
Online search
Social media
Friend/Family member
46
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.
47
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.

Our assessments are currently being completed via video clinic.

For any queries, please do not hesitate to get in contact with us at info@firststepsed.co.uk or give us a call on 01332 367571.
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