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Refer a patient to FREED

Please complete the below form to support the FREED referral process.

This form does not need to be completed by a clinician - anyone can make a referral to the FREED team. If you are unsure whether this is an appropriate referral, you can consult the diagnostic criteria and other information here.

All inappropriate referrals will be sent back to the referrer with recommendations attached, or signposted to the appropriate agencies if they are not suitable for specialist services.

If you have any questions before completing this form, please email navigo.rharianfieldsoutpatients@nhs.net or call (01472) 808450.

Refer to FREED

Referral date Required

Diagnosis Required

Details of person being referred

Title Required

Forename Required

Surname Required

Date of birth Required

Home address

Address 1

Address 2

City

State/Province

Country

Postal Code

Telephone number Required

Alternative telephone number

Email address

Preferred communication method Required

Telephone

Please tick the box below if the service user give us permission to leave a message via text, email or voicemail

They are happy for you to leave messages

Ethnicity

NHS number (if known)

Religion

Medical details

GP's Name Required

Surgery address

Address 1

Address 2

City

State/Province

Country

Postal Code

GP telephone number Required

Source of referral

Name or agency Required

Referrer's address

Address 1

Address 2

City

State/Province

Country

Postal Code

Referrer's telephone number Required

Referrer's email address Required

Is the client aware of this referral? Required

Yes

Date of last contact Required

Current presentation

To assist, please consult the diagnostic criteria which will help you complete this section. This will open in a new window.

Summary of presenting condition Required

We will now ask you to provide a set of physical monitoring data. If you do not have access to record these, please tick this box.

I am unable to send this data

Current Body Mass Index

Height

Weight

The specific bloods required are FBC, U&E, Phosphate, Calcium, Magnesium, Albumin, CRP, LFT, Iron profile, Vitamin B12 and Folate , Vitamin D, TFT, Glucose, CK.

Please upload bloods below

Does the person show any abnormalities in chemical pathology including U&Es, creatinine, LFT, glucose and TFT?

Yes

Please upload the latest ECG

Does the person present with unresolved alcohol or illicit substance misuse? If yes, please specify.

Does the person show any neurological issues? If yes, please specify.

Are the any concerns related to person’s medical condition? If yes, please specify below.

Are there current risk factors? If yes, please specify below.

Does the person have a current treatment plan? If so, please specify below.

Is this person currently using any medications? If so, please specify below.

Does this person think they have an eating problem?

Yes

Is the person pregnant or on maternity leave?

Yes

Prefer not to say

Has the person been provided with specialist eating disorder input before? If yes, specify below.

Please tick the below box Required

I have read and agree to the terms of the privacy policy

BACK TO MAIN FREED PAGE

Navigo Health and Social Care CIC. Registered in England and Wales.
Company Registration No: 07458926.
Need help now? Call 01472 256 256 or freephone 08081 968442

Registered Office: Navigo House, 3 – 7 Brighowgate, Grimsby, DN32 0QE
Telephone: 01472 583000
Fax: 01472 583000 / Email: info.navigo@nhs.net