Process - Physician - Fraser Health Authority

Adult Eating Disorders ProgramReferrals to: Tri-Cities Mental HealthCentre#1—2232 Elgin AvenuePort Coquitlam, B.C., V3C 2B2Tel (604) 777-8400 Fax (604) 777-8411www.fraserhealth.caDate:NEW CLIENT REFERRALFraser North Eating Disorders ProgramReferral Criteria:The Eating Disorder Program services clients with eating disorders as outlined in the DSM IV. The client will have:a) An intense preoccupation and concerns with body shape and sizeANDb) Significant low weight or weight loss due to voluntary restricting of food intake (i.e. 15% of baseline normal weight).ORc) Binge eating more than two times per week for three months accompanied by feeling out of control (i.e. can’t stop binge orcontrol how much is eaten) and purging behaviour (i.e. vomiting, laxatives, post-binge fasting, excessive exercise…).Exclusion criteria:The EDP does not provide services in the following instances:1. The patient is under 19 years of age.2. Alcohol or substance abuse is the primary presenting problem.3. The client does not have a General Practitioner/Primary Family Physician. Given our limited resources, the EDP can not be asubstitute for a client’s General Practitioner. As such referrals of individuals who do not have a family physician can not beaccepted.4. The client is acutely suicidal or in crisis.5. Acute psychiatric disorders account for decreased food intake such as: Thought Disorders (e.g. someone with schizophrenia who has delusions around food). Major Depression or Post Partum Depression where decreased food intake is due to mood.6. Binge eating disorder (i.e. binge eating without any compensatory behaviour).7. The client is not a resident of the Fraser North Health Area.Referral Source: (Family Physician)Name:Office Phone:Address:Office Fax:Client Information – Please complete:Client’s Surname:Client’s First Name:Current Address (include postal code):Gender:MDOB: (mm/dd/yy)FHome Phone # Work Phone #PHN:1