Self-referral form for Norfolk and Waveney under 18 eating disorder service

Self referral form for under 18 Eating disorder services

Your information

Note: Questions marked by * are mandatory

Self-referral for Norfolk and Waveney under 18’s Children and adolescent eating disorder services. Once you have completed this form, we will aim to make contact with you within 24 working hours. The team do not work weekends or Bank holidays but will review any referral received on the next working day. If you do not hear from the team, have any concerns, or do not wish to fill this form in but still want to refer please contact the team on 01603 978455 Monday to Friday 9-5pm. This is not a crisis service. If you currently do not feel you can keep yourself safe or have any concerning symptoms, please visit the 'help in a crisis' section of our website.

*This is a mandatory field. Full name

*This is a mandatory field. Preferred name

*This is a mandatory field. Pronouns

*This is a mandatory field. Date of birth

*This is a mandatory field. Address

*This is a mandatory field. GP practice

*This is a mandatory field. GP name

*This is a mandatory field. Parent or carers names

*This is a mandatory field. Parents contact number

*This is a mandatory field. Consent to contact parents/carers?

Yes
No

* Spam Guard: How many legs does a dog have? (Write the number as a word.)