ARFID - Child & Adolescent Registration Form

Form

Name of Parent or Guardian of Young Person

Name, number and relationship to young person

Emergency Contact Email Address

Please enter the email address

First Name of Young Person

Surname of Young Person

Date of Birth of Young Person

Sex

Gender Identity

Preferred Pronouns (optional)

Address Line 1

Address Line 2

Address Line 3

City

Postcode

Telephone

Email

GP Name

GP Address

{name}

GP Email

GP Website

GP Contact - Do you give us permission to contact your GP?

Please note that for a medical appointment with our Consultant Psychiatrist, we will require consent to contact your GP.

Is your GP aware of the concerns you have for your young person?

Is your young person currently under the care of a paediatrician?

Do you intend to use a private health insurance policy?

Invoicing Information

For invoicing purposes, please provide the name, email address and mobile number for the person responsible for payment (N.B. Please note once an appointment is confirmed we do require 24 hours notice for any cancellations otherwise the appointment will be charged in full)

How did you find us?

If you have a preference for days and/or times you are able to be seen, please let us know

{name}

Would you prefer to be seen in London, Manchester, Hertford, Richmond or remotely

(please type your answer in the box below - note that a combination of in person and remote is fine)

{name}

New Client Questionnaire Please note the following questionnaire is OPTIONAL, and is requested only if you are comfortable to disclose information in this way. The questions are aimed at helping us to gain a better understanding of your current situation and will be used to inform decisions about which treatment approach or which clinician may be most appropriate to assess you. In cases of high physical risk, or complex developmental comorbidity, it may be that we suggest an onward referral pathway, or require a paediatric referral prior to assessment.

Has your young person received any previous medical, psychiatric or developmental diagnoses?

(please include any ongoing medical investigations or queried diagnoses)

Has your young person previously received treatment for any of the diagnoses shared above?

(please include any ongoing medical investigations or queried diagnoses)

Please briefly describe your young person’s eating habits.

It would be helpful if you could complete a food and drink record for up to 5 days prior to your assessment.

{name}

At what age did the above difficulties appear to start?

Was there any obvious triggers to this onset? e.g. choking, physical illness, stress or anxiety in the young person or family, other

{name}

Current Weight (if known)

please approximate if unknown

{name}

Current Height (if known)

{name}

Do you currently have any concerns in relation to your young person’s mood?

Eg. mood swings, depression, anxiety, mania, suicidality, deliberate self-harm, or other…

Are you or your young person currently experiencing any other difficulties in your life that are not related to the above questions?

Eg. relationship problems, family problems, work stress, bereavement, other mental health concerns, physical health problems, or other…

What are you hoping to get out of an assessment with your young person?

{name}

Is there anything you feel we should be aware of prior to meeting with your young person?

Alert