Process - Physician - Fraser Health Authority

Fraser South Eating Disorders Program#129 – 6345 120 th StreetDelta, BC V4E 2A6Phone:Date:604.592.3700 Fax: 604.591.2302NEW CLIENT REFERRALAdult Program - Fraser South 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 baselinenormal 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 or control how much is eaten) and purging behaviour (i.e. vomiting, laxatives, post-bingefasting, excessive exercise…).Exclusion criteria: The EDP does not provide services in the following instances:1. Alcohol or substance abuse is the primary presenting problem.2. The client does not have a General Practitioner. 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 familyphysician can not be accepted.3. The client is acutely suicidal or in crisis.4. Acute psychiatric disorders that 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.5. Binge eating disorder (i.e. binge eating without any compensatory behaviour).6. The client is not a resident of Fraser South Health Area.Referral Source: (Must Be A Family Physician)Name:Office Phone:Office Fax:Address:Client Information – Please complete:Client’s Surname:Client’s First Name:Gender:MFDOB: (yyyy/mm/dd)Current Address (include postal code):Home Phone # Work Phone #Contact Name (Next of Kin) Home Phone #Work Phone #Relationship to patient:PHN:Program:Adult1