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.

MD agreement to medical monitoring:

Regarding my patient:
I verify that:
My patient does not meet admission criteria as per the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders, below.
My patient is suitable to attend outpatient treatment at CFIH
I will monitor my patient’s medical status regularly as per the below guidelines.

This information is true and accurate to the best of my knowledge. This acceptance constitutes my signature.
Accept here:

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 assessedAdult admission criteriaChild admission criteria
WeightBMI <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 wavesQTc >450msec
Glucose<2.5mmol/L (random)
Electrolytes*Potassium – <3.0mmol/L; Sodium – <125mmol/L
Phosphate & Magnesium - Below normal range
Hypokalemia
eGFR<60ml/min/1.73m2 OR rapidly dropping (25% within a week)
Albumin<30g/L
Liver enzymesMarkedly elevated (AST or ALT >500)
Neutrophils<1.0 x 109/LNeutropenia
Psychiatric CriteriaModerate 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.

See also: Guidelines – more info here

Client consent Forms