Kent and Medway Eating Disorder Service Client Details Section 1 Client’s Name: M F Date of Birth (Surname) (First Name) Address: Client of Contact: ’s Preferred Method Letter: Letter: Text: Email: Postcode: Email Address: First Language: Interpreter required: Yes No Home Telephone: Client Mobile: Specify Which Language: ’s Does the client have a disability: Social Services ISIS Number Yes No NHS Number: (if applicable): Please specify: Religion: Nationality: Ethnicity: GP Name: GP Telephone Number: GP Surgery Address: (If applicable) Subject to Child Protection Plan / Child In Need: Y N Email LAC Status: Attends school/college Marital Status: Employed Unemployed Dependent Children: Yes No Name of School / College (if applicable): Smoking Status : Non Smoker Smoker Address: Substance Use Status: Alcohol Telephone: Recreational substances Contact Name: Controlled drugs To Be Completed for < 18 Year Clients Section 2 Next of Kin and Parental Responsibility Details: Interpreter required: Yes No Name of Person(s) with Parental Responsibility? Specify Which Language: Parent / Name (if different from above): Relationship to Young Person: Carer’s Telephone: Address: Postcode: Mobile: Email Address: Reason for Referral and Details about Client Difficulties: ’s state nature of difficulties, Section 3 onset, frequency, duration, interventions tried, any relevant medical history (Please note weight, height and BMI are mandatory fields and the referral cannot be processed without this information)
Kent and Medway Eating Disorder Service Section 1 Client Details Client’s Name: (Surname) (First Name) M F Date of Birth Address: Client ’s Preferred Method of Contact: Letter: Letter: Text: Email: Postcode: Email Address: First Language: Home Telephone: Client ’s Mobile: Interpreter required: Yes No Specify Which Language: NHS Number: Social Services ISIS Number (if applicable): Does the client have a disability: Yes No Please specify: Religion: Nationality: Ethnicity: GP Name: GP Telephone Number: GP Surgery Address: Email (If applicable) Subject to Child Protection Plan / Child In Need: Y N LAC Status: Attends school/college Employed Unemployed Marital Status: Dependent Children: Yes No Name of School / College (if applicable): Address: Telephone: Contact Name: Smoking Status : Non Smoker Smoker Substance Use Status: Alcohol Recreational substances Controlled drugs Section 2 To Be Completed for < 18 Year Clients Next of Kin and Parental Responsibility Details: Name of Person(s) with Parental Responsibility? Interpreter required: Yes No Specify Which Language: Parent / Carer’s Name (if different from above): Relationship to Young Person: Address: Postcode: Telephone: Mobile: Email Address: Section 3 Reason for Referral and Details about Client ’s Difficulties: state nature of difficulties, onset, frequency, duration, interventions tried, any relevant medical history (Please note weight, height and BMI are mandatory fields and the referral cannot be processed without this information)