<Please call the triage officer on (08) 9224 4242 to discuss ALL referrals prior to sending.>Please call the triage officer on (08) 9224 4242 to discuss ALL referrals prior to sending.
Send this form to EMEDSSReferrals@health.wa.gov.au or fax to (08) 9224 4243	
EMEDSS offers an intensive, recovery-focused outpatient eating disorder program of combined medical monitoring and specialist multidisciplinary evidence-informed therapies including psychology and dietetics. It is important for patients and referrers to understand that the service is time-limited to 12 weeks and requires a high level of commitment and engagement from the patient. The EMEDSS team will assess the needs of the patient and determine who the patient sees and frequency. 	
INCLUSION CRITERIA – ALL CRITERIA MUST BE MET<INCLUSION CRITERIA – ALL CRITERIA MUST BE MET><Tick all that apply>	
<Agreeable to engaging with the service>Agreeable to engaging with the service
<Willing to attend weekly appointments as a minimum, as determined by clinical need> Willing to attend weekly appointments as a minimum, as determined by clinical need
<Aged 16 years and older>Aged 16 years and older
<Eating disorder as a diagnosis of primary concern and/or is diagnosed with an eating disorder>Eating disorder as a diagnosis of primary concern and/or is diagnosed with an eating disorder
<Resides within the EMHS catchment>Resides within the EMHS catchment 
<Medically stable – can be maintained in the community or out of hospital>Medically stable – can be maintained in the community or out of hospital
<Engaged with a GP in the community or is willing to do so on an ongoing basis>Engaged with a GP in the community or is willing to do so on an ongoing basis	
EXCLUSION CRITERIA – if any apply, please call triage officer 9224 4242<EXCLUSION CRITERIA><If none apply, tick nothing. If any apply, please reconsider if this is the right service for your patient or call the triage officer on 9224 4242 for further advice>	
<Acute risk of self-harm or suicide not manageable in a community setting>Acute risk of self-harm or suicide not manageable in a community setting
<Active substance or alcohol use resulting in regular intoxication impacting the ability to engage effectively with EMEDSS>Active substance or alcohol use resulting in regular intoxication impacting the ability to engage effectively with EMEDSS
<Active psychosis>Active psychosis
	N.B. In certain circumstances, we may be able to see these patients under a shared care arrangement with a community mental health team or drug and alcohol service	
Referral completed by:  <Referral completed by>	
REFERRER              	Name:  <DrName>	Service:<Practice>	
	Phone:<DrPhone>	Fax:<UsrFax>	
	Email:<DrEmail>		
NEXT OF KIN/ NOMINATED PERSON	Name: <NOKName>	Relation:<NOKRelation>	
	Phone:<NOKContact>	Address:<NOK Address (if different from patient)>	
Usual GP 
(If different to referrer)	Name:<DrName>	Practice:<Practice>	
	Phone:<UsrPhone>	Fax: <UsrFax>	
	Email: <PracEmail>		
COMMUNITY SUPPORTS<Please give the details of the patient's existing community supports below if applicable>	Dietitian: <Name of Dietician>	Clinical Psychologist: <Name of Clinical Psychologist>	
	Psychiatrist: <Name of Psychiatrist>	Other:	
IS THE CONSUMER CURRENTLY AN INPATIENT?  <Is the patient currently an inpatient>    	
If YES, specify:<The following 3 questions only apply if an inpatient>	Hospital: <If yes, please specify which hospital:>	Treating Team/Ward: <Which Team/Ward:>	
	Treating Psychiatrist:<What is the name of their treating psychiatrist>		
IS THE CLIENT CURRENTLY ACTIVE WITH A COMMUNITY MENTAL HEALTH TEAM? <Is the patient currently active with a community mental health team?>	
If YES, specify:<The following two questions only apply if they are active with a community mental health team>	Clinic:<If yes, please specify which clinic:>	
	Treating Psychiatrist:<Please specify name of psychiatrist if known>	
EATING DISORDER ASSESSMENT <EATING DISORDER ASSESSMENT>	
Diagnosis: <Diagnosis (e.g. Anorexia Nervosa, Atypical Anorexia Nervosa, Other specified feeding or eating disorders (OSFED), Eating Disorders Not Otherwise Specified (EDNOS), Binge Eating Disorder, Avoidant/restrictive food intake disorder (ARFID) etc)>
	
<EATING DISORDERS BEHAVIOURS - tick all that apply><Dietary Restriction>Dietary Restriction  <Vomiting> Vomiting   <Bingeing>Bingeing    <Over exercise>Over exercise  <Laxatives>Laxatives  <Diuretics/ diet pills>Diuretics/ diet pills          
Provide details if ticked:  <Please provide further details if you have ticked any of the above>
	
Weight history	
Height:   <Patient Height (in cm)> cm    	Weight:        <Patient Weight (in kg)>  kg             	Date: <Date the following weight was taken (today preferred)>	BMI:    <BMI>          kgm2 	
Highest weight:  <Highest ever weight> kg	Lowest weight: <Lowest ever weight>kg	
RISK ASSESSMENT <The following questions are about risk assessment>	
<Suicidal thoughts/ intent/ plan?>Suicidal thoughts/ intent/ plan                	<Self- harming?> Self- harming, specify: <If yes to self harming, please specify>	
<Impulsivity?>Impulsivity 	<RAMP is attached (not required from GPs)>RAMP attached (not required from GPs)	
<History or current family domestic violence?>History or current family domestic violence	
<Substance use (inc. alcohol and other drugs)?>Substance use (inc. alcohol and other drugs), specify: <If yes to substance use (inc. alcohol and other drugs), please specify:>	
Provide details if ticked & any other relevant background risk/ additional information: <Any other details or relevant background information/risk:>

MEDICAL ASSESSMENT AND OTHER RELEVANT HISTORY <MEDICAL ASSESSMENT><The following questions pertain to the medical status of the patient. If the patient is currently an inpatient they need to be within 48 hours of referral, if an outpatient they need to be 1 week old or less>	
Date of observations:  <Date the following observations were taken>                  (Required – within 48 hours if inpatient, within 1 week if outpatient) 	
BP: Lying <Lying BP>	Standing (3min) <Standing BP (at 3 minutes)>	HR: Lying <Lying HR>	Standing (3min) <Standing HR (at 3 minutes)>	
BSL <Blood Sugar Level>	RR <Respiratory Rate/SpO2>	Temp <Temp>	Amenorrheoa <Does the patient have amenorrhoea?>	
<The following questions are in regards to investigation results of the patient. If the patient is currently an inpatient they need to be within 48 hours of referral, if an outpatient they need to be 2 weeks old or less> Date of investigations:  <Date of investigations>                 (Required within 48 hours if inpatient, within 2 weeks if outpatient) 	
<Please attach an ECG and tick this box to indicate you will do so>ECG attached 	
<Please attach blood results and tick this box to indicate you will do so. Please include FBE, LFTs, UEC, Mg, PO4, Calcium. If you have any other recent or relevant investigation results please attach them also>Blood results attached - FBC, LFT, UEC, Mg, Po4, Ca	
Physical concerns: <Does the patient have any of the following physical concerns?> <If ticked other, please specify here:>Other, specify:

Past Medical History: <PMHAll>
	
Psychiatric Diagnoses/History/Concerns: <Details of any previous psychiatric diagnoses/history or concerns>
	
Previous Admissions (Medical/Mental Health, attach discharge summary if available): <Details of any previous medical or mental health admissions (Please attach discharge summary if available)>
	
Current Medications: <CurrentRx>
	
<CLINICAL GOVERNANCE - Tick this box to acknowledge that you understand EMEDSS does not assume clinical governance until the client has commenced treatment with the service. EMEDSS will notify the client, the GP (and the referrer if not the GP) once a client has commenced. This does not include triage appointments.>I understand EMEDSS does not assume clinical governance until the client has commenced treatment with the service. EMEDSS will notify the client, the GP (and the referrer if not the GP) once a client has commenced. This does not include triage appointments.
<GP'S REFERRING FROM THE COMMUNITY - tick this box to acknowledge that you understand that in the interim, you are responsible for providing medical monitoring for the client and that you will forward observations and bloods of each medical monitoring visit to EMEDSSReferrals@health.wa.gov.au. EMEDSS recommends at least weekly monitoring or more frequently if medically indicated. A template for medical monitoring will be emailed to you.>For GPs referring from the community - I understand that in the interim, I am responsible for providing medical monitoring for the client and that I will forward observations and bloods of each medical monitoring visit to EMEDSSReferrals@health.wa.gov.au. EMEDSS recommends at least weekly monitoring or more frequently if medically indicated. A template for medical monitoring will be emailed to you.
<REFERRALS FROM INPATIENT - please tick this box to ackowledge you will advise the patient to make an appointment with their GP for medical monitoring on discharge (unless an appointment with EMEDSS has already been arranged within 1 week of discharge)>For referrals from inpatient – I will advise the patient to make an appointment with their GP for medical monitoring on discharge (unless an appointment with EMEDSS has already been arranged within 1 week of discharge)	
<PLEASE REMEMBER TO ATTACH BLOOD/OTHER INVESTIGATION RESULTS, DISCHARGE SUMMARIES, ECG ETC AT THE END>ATTACH – MH ASSESSMENT FORM, LEGAL FORMS, RAMP, DISCHARGE SUMMARY, RECENT BLOODWORK, ECG, HEALTH SUMMARY (GPs) as appropriate	
Once you have spoken to EMEDSS triage officer on 9224 4242, please send referral to: EMEDSSReferrals@health.wa.gov.au	
SIGNATURE:	<DrName>	DESIGNATION:	<DrQualifications>	DATE:	<TodaysDate>