Referrer Eating Disorders Management Plan (EDMP)

If you are looking to create an EDMP for a patient whom you intend on referring to CFIH, please complete our "Referral form & GP Management Form" which includes a CFIH referral form, medical clearance form, and GP management form all in one.

If you are looking for CFIH's medical clearance or medical monitoring forms, you can find the adult form here and the under 18's form here.

Referrer Details

Referral date *

Referrer's name *

Provider number *

Practice name & contact details *

Email address: *Please provide the email address you'd like a completed copy of this form sent to.

Patient Details

First name *

Last name *

Date of birth *

Age

Does the patient consent to the referral? *

YesNoN/A

Phone number *

Email address

Eligibility for EDMP

Eating Disorder Diagnosis *

Anorexia Nervosa (AN)Bulimia Nervosa (BN)Binge Eating Disorder (BED)Other Specified Feeding or Eating Disorder (OSFED)

For BN, BED, and OSFED diagnoses, the following additional criteria must be met (below)

EDE-Q Global ScoreScore ≥ 3 for eligibility

Eating Disorder Behaviours *

Rapid weight lossBinge eating (frequency ≥ 3 times/week)Inappropriate compensatory behaviour (e.g., purging, excessive exercise, laxative abuse) (frequency ≥ 3 times/week)

At least 1 for EDMP eligibility

Clinical Indicators *

Clinically underweight (<85% expected weight with weight loss due to eating disorder)Current or high risk of medical complications due to eating disorderSerious comorbid psychological or medical conditions impacting functionHospital admission for eating disorder in the past 12 monthsInadequate response to evidence-based eating disorder treatment over past 6 months

At least 2 for EDMP eligibility

EDMP Eligibility Met *

YesNo (consider Mental Health Care Plan and/or Chronic Disease Management Plan)

Initial Treatment Recommendations Under EDMP

Psychological Treatment Services

Dietetic Services

Psychiatric/Paediatric Review *Assessment by psychiatrist/pediatrician is required for the patient to access EDMP psychological sessions 21-40

Referred to:

Treatment Goals *For example: Restore/stabilise weight, reverse malnutrition, reduce compensatory behaviours, address body image disturbance

Physical Assessment

Assessment:

Moderate Alert - Monitor Weekly

High Alert - Meets Admission Criteria

BMI

BMI < 16

BMI < 13

Weight Loss

Weight loss >0.5kg for several weeks

Weight loss 1kg or more for several weeks

Blood Pressure

Systolic - 90mmHg

Diastolic - 60mmHg

Systolic - 80mmHg

Diastolic - 50mmHg

OR postural drop >10mmHg

Heart Rate

<50bpm

<40bmp

OR postural tachycardia >20bpm increase

Temperature

<36° C

<35.5° C

OR cold/blue extremities

Fluid and electrolyte changes

Phosphate: 0.5-0.9mmol/L

Potassium: <3.5mmol/L

Sodium: <130mmol/L

Phosphate: <0.7mmol/L

Potassium: <3.0mmol/L

Sodium: <125mmol/L

Liver enzymes

AST >40

ALT >45

AST >100

ALT >100

Nutrition

Albumin <35g/L

Glucose <3.5mmol/L

Albumin <30g/L

Cardiovascular - ECG

<50

<40

OR prolonged QT interval >450msec

OR arrythmias

eGFR

-

<60ml/min/1.73m²

OR rapidly dropping (25% within a week)

Bone marrow

Neutrophils <1.2 x 10⁹/L

Neutrophils <1.5 x 10⁹/L

Physical Observations

Swollen ankles

Pitting oedema

Significant bruising

-

Referral Requirements

Please bill MBS item #90250-90253 (more information on billing codes can be found here)

Patient education given *

Yes No

Physical examination conducted *

Yes No

Copy of EDMP given to patient *

YesNo

Consent

I (patient), *

agree to information about my mental and medical health to be shared between the GP and the health professionals to whom I am referred, to assist in the management of my health care.

Signature (patient) *

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I (referrer), *

have discussed the proposed referral(s) with the patient and am satisfied that the patient understands the proposed uses and disclosures and has provided their informed consent to these.

Signature (referrer) *

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CAPTCHA *