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ISLAND HEALTHRegional Eating Disorders Program: Client Referral FormIn the continuum of care for eating disorders treatment on Vancouver Island, this referral form is sharedby all Island Health Outpatient Eating Disorder Programs. Inclusion criteria may vary by program (seebelow boxes).The following are generalized Exclusion criteria:a) The client is actively suicidalb) Non-eating disorder psychiatric disorders account for decreased food intake (i.e. thoughtdisorders with delusions around food)c) Alcohol or substance misuse is the primary presenting problemRecognizing there is complex comorbidity in this population, contact the Regional Coordinator - CrystalFrost - for further discussion if needed 250-519-5390 X 36925Please read the following guidelines carefully – For the most current program information/ReferralForm, check Pathways with the Divisions of Family PracticeReferring to Central Island Child & Youth Eating Disorders Program:For Clients up to and including 19 years of age with confirmed or suspected eating disorder asoutlined in the DSM V: Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BN),Avoidant Food Intake Disorder (ARFID) and Other Specified Feeding & Eating Disorder (OSFED)Referrals are accepted from General Practitioners and Nurse Practitioners for those 13-19 years ofageReferrals are accepted from Pediatricians for those 12 years of age and underAll other health care professionals wishing to refer, please liaise with a primary care practitioner onreferral completion. If this is not feasible, please contact the Eating Disorders Program at the phonenumber below.Referrals are accepted from Geography 2 including the following regions: Ladysmith, Nanaimo,Oceanside, Alberni Valley, West CoastFax referral to: 250-739-5944Phone Number: 250-755-7955Referring to Central Island Adult Eating Disorders Program:For Clients 19 years of age and older with confirmed or suspected eating disorder as outlined in theDSM V: Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BN), Avoidant FoodIntake Disorder (ARFID) and Other Specified Feeding & Eating Disorder (OSFED)Referrals are accepted from General Practitioners and Nurse PractitionersAll other health care professionals wishing to refer, please liaise with a primary care practitioner onreferral completion. If this is not feasible, please contact the Eating Disorders Program at the phonenumber below.February 2022
ISLAND HEALTHReferrals are accepted from Geography 2 including the following regions: Ladysmith, Nanaimo,Oceanside, Alberni Valley, West CoastFax referral to: 250-739-5974Phone Number: 250-755-7691 X 54019Referring Clients to North Island Eating Disorders Program (Youth & Adults):For clients with confirmed or suspected eating disorder as outlined in the DSM V: Anorexia Nervosa(AN), Bulimia Nervosa (BN), Binge Eating Disorder (BN) and Other Specified Feeding & Eating Disorder(OSFED)Referrals are accepted from General Practitioners, Nurse Practitioners and PediatriciansAll other health care professionals wishing to refer, please liaise with a primary care practitioner onreferral completion. If this is not feasible, please contact the Eating Disorders Program at the phonenumber below.Referrals are accepted from Geography 1 regions: Comox Valley, Strathcona, North IslandComox Valley Fax Referral to: 250-331-5903Phone Number: 250-331-5900Campbell River Fax Referral to: 250-850-2464Phone Number: 250-850-2620 X 62962Future ServicesReferring Clients to Cowichan Valley Eating Disorders Program:For clients with confirmed or suspected eating disorder as outlined in the DSM V: Anorexia Nervosa(AN), Bulimia Nervosa (BN), Binge Eating Disorder (BN), Avoidant Food Intake Disorder (ARFID) andOther Specified Feeding & Eating Disorder (OSFED)Referrals are accepted from General Practitioners, Nurse Practitioners and PediatriciansAll other health care professionals wishing to refer, please liaise with a primary care practitioner onreferral completion. If this is not feasible, please contact the Eating Disorders Program at the phonenumber below.Referrals are accepted from Shawnigan Lake, Duncan, Chemainus, Lake Cowichan , North Cowichan,Mill Bay, LadysmithFax Referral to:Phone Number:Team Incudes an adult therapist and a dietitian (youth & adults). For youth, initial referral should gothrough Child & Youth Mental Health Fax 250-715-2789.To connect with the Regional Eating Disorders Coordinator call: 250-519-5390 xtn 36925 or email:crystal.frost@islandhealth.caFebruary 2022
ISLAND HEALTHWhere are you referring to? (Select one):Central Island Child & Youth Eating Disorders Program/ Fax referral form to: 250-739-5944Central Island Adult Eating Disorders Program / Fax referral form to: 250-739-5974North Island Eating Disorders Program / Comox Valley Fax referral form to: 250-331-5903/Campbell River Fax referral form to: 250-850-2464Cowichan Valley Eating Disorders Program / Fax referral form to:Referring Primary Care Provider Information – All patients must have a GP, NP, orWalk-In Clinic that will follow them. The Information provided will be used fortriaging purposes.DateDoctor’s Name (First)Doctor’s Name (Last)Office PhoneDr Office Stamp:Office FaxOffice AddressCityPostal CodeClient InformationIs client aware and in agreement of this referral for eating disorder servicesIf Youth, is the parent also awareYesNoLegal Last NameLegal First NameYesMiddle Names(s)Preferred NameNoIf referring for youth – Parent NameGenderBC PHNFebruary 2022MaleFemaleNon-BinaryTransOther
ISLAND HEALTHStreet AddressCity / Postal CodeClient Phone Number (home)OK to leave voicemails? YesNoCell/other:OK to leave voicemails? YesNoEmail address:If referring for youth, Parent ContactOK to leave messages YesNoAre you referring to another service in conjunction with this referral? Yes (service:) NoEating Disorder Related Information – to be completed by primary care providerMeasured HeightIn / cmMeasured Blinded Weight:Please send growth chart if under 18 years of agelbsAny weight loss in the past 3 monthsYesAmount NoAny weight loss in the past 6 monthsYesAmount NoHeart RateResting: Sitting:Orthostatic BP Resting: Sitting:Fear of Weight GainYesNoRestrictionYesNoLess than 1 meal equivalent/dayLess than 2 meal equivalent/dayLess than 3 meal equivalent/dayOver-ExerciseCurrent # hours/dayYesNoSelf Induced Vomiting YesNoHow many time per dayHow many days per weekBlood in emesisYesMedications for Weight LossLaxative abuseInsulinIpecacStimulantsDiet PillsFebruary 2022NoYesNoType and frequencyDetailsDetailsDetailsDetails/ kg
ISLAND HEALTHDiureticsThyroid medsDetailsDetailsBinge Eating (objectively large amount eaten within any 2 hour period that feels out of control)YesNoHow many time per day How many days per weekMedical History - to be completed by primary care providerAmenorrhea YesNoDate of last periodIf amenorrheic 6 months, please order DEXA/BMD Scan and forward resultsBirth Control PillsYesNoPregnantYesNoWeek of pregnancy at referralDiabetes (insulin dependent) YesNoDetailsGI Disorder (e.g. Crohn’s Celiac, GERD) YesNoDetailsSubstance/ETOH MisuseYesNoDetailsOther Medical Concerns (please specify)Current Medications (please list type & dosage)Confirmed Allergies*Mandatory Labwork & ECG Must Accompany Referral – please forward current results:CBC, Random Glucose, Na, K , Cl, Bicarbonate, Ca, Mg, PO4, Ferritin, B12, Cr, BUN, AST, ALT, Alk Phos,TSH, Microscopic urinalysis to include specific gravity (LH, FSH, estradiol if genetically female,testosterone if genetically male)ECG – For BaselinePsychiatric HistoryPlease describe any psychiatric symptoms of concern, or current diagnosesSelf HarmYesSuicidal Ideation YesNoPlease describeNoCurrent or Past Attempts (when & how)Previous hospitalization or tertiary care admissions related to mental health or eating disorder concernsFebruary 2022
ISLAND HEALTHPerceived readiness for eating disorder treatmentCurrently working with other therapists or cliniciansYesNoIf yes, names of Clinician/Therapist(s)Physician/NP DSM 5 DiagnosisAnorexia Nervosa, Restricting type (AN/R)Anorexia Nervosa, Binge/Purge type (AN/BP)Bulimia NervosaAvoidant Restrictive Food Intake Disorder (ARFID)Binge Eating Disorder (BED)Other Specified Feeding & Eating Disorder (OSFED)DisclaimerI understand that the eating disorder program is an outpatient eating disorders service and is unableto assume responsibility for the primary medical care of this client. Ongoing primary care is theresponsibility of the Primary Care Provider.Primary Care Providers SignatureDateRoutine Medical Monitoring1. Regular supportive meeting to check-in regarding meals, eating disorder behaviours, andmedical symptomsa. BLIND (backwards) weight, with no mention of numbers or body appearance, isrecommended to avoid triggering relapse or worsening of symptomsb. Postural vital signs*The Central Island Child & Youth Eating Disorders Program can provide regular monitoring of weightand vitals as indicated2. Routine investigations: ECG and bloodwork including CBC, electrolytes, Ca, Mg, PO4, kidneyfunction, liver function and random glucose.NOTE: Frequency of visits and investigations depends on symptoms and clinical judgement (for example,frequency of purging or restriction with rapid weight loss needs close monitoring (q 1-2 weeks), whereaspatients with less severe behaviours can be monitored less frequently (q 4-8 weeks). Please see theEating Disorders Toolkit for Primary Care Practitioners: ebruary 2022
If this is not feasible, please contact the Eating Disorders Program at the phone number below. Referrals are accepted from Geography 2 including the following regions: Ladysmith, Nanaimo, Oceanside, Alberni Valley, West Coast . Fax referral to: 250-739-5944 . Phone Number: 250-755-7955 .
