Client Outpatient Referral Form
For all referrals:
Please provide a Mental Health Care Plan (MHCP) or Chronic Disease Management Plan (CDMP) if relevant.
For diagnosed or suspected eating disorders:
In addition to a MHCP or CDMP, please also complete and submit the following information to CFIH, prior to your patient’s initial appointment.
Please submit this completed form prior to your patient’s initial appointment at CFIH.
If you would prefer to submit a paper version of this form please download it here: Referral Form PDF
Once completed it can be emailed or sent to CFIH via fax on (07) 3172 5851.
Royal Australian and New Zealand College of Psychiatrists medical admission guidelines for the treatment of eating disorders:
|Areas to be assessed||Adult admission criteria||Child admission criteria|
|Weight||BMI <12; weight loss 1kg or more for several weeks OR grossly inadequate nutritional intake (<1000cals daily) OR continued weight loss despite community treatment||< 75% of expected body weight OR rapid weight loss|
|Blood Pressure||< 80mmHg systole OR postural drop >20mmHg upon standing||<80/50mmHg resting OR postural drop >20mmHg upon standing|
|Heart Rate||<40bpm or 120bpm resting OR postural tachycardia >20bpm increase upon standing||<50bpm resting OR postural tachycardia >20bpm increase upon standing OR cardiac arrhythmia|
|Temperature||<35° C OR cold/blue extremities||<35.5° C OR cold/blue extremities|
|12-lead ECG||<40bpm or 120bpm resting OR postural tachycardia >20bpm increase upon standinginversion or biphasic waves||QTc >450msec|
|Electrolytes*||Potassium – <3.0mmol/L; Sodium – <125mmol/L|
Phosphate & Magnesium - Below normal range
|eGFR||<60ml/min/1.73m2 OR rapidly dropping (25% within a week)|
|Liver enzymes||Markedly elevated (AST or ALT >500)|
|Neutrophils||<1.0 x 109/L||Neutropenia|
|Psychiatric Criteria||Moderate to high suicidal ideation; Active self-harm; Other psychiatric condition requiring hospitalisation|
*Patients who are not as unwell as indicated above may still require admission to a psychiatric or other inpatient facility.