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Process - Physician - Fraser Health Authority

Process - Physician - Fraser Health Authority

Process - Physician - Fraser Health Authority

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<strong>Fraser</strong> South Eating Disorders Programc/o Child and Youth Mental <strong>Health</strong> (CYMH)Surrey North Intake Officeph 604.951.5844 fax: 604.951.5917Date:NEW CHILD & YOUTH CLIENT REFERRAL<strong>Fraser</strong> 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…).NB: Referral for clients that are pre-pubescent must come from a paediatrician.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 age 12 or under and is not referred by a paediatrician.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 <strong>Fraser</strong> South <strong>Health</strong> Area.Referral Source: (Family <strong>Physician</strong> or Paediatrician if age 12 or under)Name:Office Phone:Address:Client Information – Please complete:Client’s Surname:Client’s First Name:Office Fax:Gender:MFDOB: (yyyy/mm/dd)Current Address (include postal code):Home Phone # Work Phone #Parent/Guardian Name: Home Phone #Work Phone #Parent/Guardian Name: Home Phone #Work Phone #May we contact the Client’s Parents/Guardian? Yes NoPHN:Program:Child & Youth1

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