CFIH Referral Form & GP Management Plan

In our efforts to ensure the health and safety of all patients visiting our clinic, we require a CFIH referral form be completed along with medical clearance for outpatient treatment (both included in the form below). 

If you believe that your patient may also be eligible for an Eating Disorder Management Plan (EDMP), Mental Health Care Plan (MHCP), Chronic Disease Management Plan (CDMP), or benefit from psychiatry input, this form also meets Medicare requirements for the relevant referrals sought. 

If you are looking to create an EDMP for a service other than CFIH, please see our generic EDMP referral form here.

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 Information

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

Patient Information

Guardian information


Eating Disorder Management Plan (EDMP)

If unsure, consider referring the patient for an assessment privately, via psychiatry referral, or under a MHCP. The assessing clinician will advise your patient's diagnosis and eligibility for an EDMP.

There are three essential features in a diagnosis of Anorexia Nervosa: persistent energy intake restriction (leading to an impact on the patient's physical or psychological health & functioning); an intense fear of weight gain (which may be evidenced by behaviours interfering with weight gain as opposed to self-reports of feared weight gain); and a disturbance in how the patient experiences their weight/shape. 

DIAGNOSTIC CRITERIA:

  1. Restriction of energy intake relative to requirements, leading to bodyweight significantly lower than what is expected for the patient based on their age, sex, developmental trajectory, previous weight, and physical health. 

  2. Intense fear of gaining weight or "becoming fat", or persistent behavior that interferes with expected weight gain or weight regain. 

  3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low weight. 

From your assessment, it appears that your patient meets the criteria for an EDMP. If you are happy to provide the patient with this referral type, please bill MBS item #90250-90253 (more information on billing codes can be found here), and please ensure EDMP has been selected under "referral type" on the next page of this form.

If unsure, consider referring the patient for an assessment privately, via psychiatry referral, or under a MHCP. The assessing clinician will advise your patient's diagnosis and eligibility for an EDMP.

There are three essential features in a diagnosis of Bulimia Nervosa: recurrent episodes of binge eating, recurrent inappropriate compensatory behaviours to prevent weight gain, and self-evaluation that is unduly influenced by body weight and shape.

DIAGNOSTIC CRITERIA:

  1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both:

    • Eating in a discrete period of time (e.g. within any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. 

    • A sense of lack of control over eating during the episodes (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

  2. Binge eating episodes are associated with three or more of the following:

    • Eating much more rapidly than normal.

    • Eating until feeling uncomfortably full.

    • Eating large amounts of food when not feeling physically hungry.

    • Eating alone because of feeling embarrassed by how much one is eating.

    • Feeling disgusted with oneself, depressed, or very guilty afterward.

  3. Marked distress regarding binge eating is present.

  4. The binge eating occurs, on average, at least once a week for 3 months.

  5. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in Bulimia Nervosa and does not occur exclusively during the course of Bulimia Nervosa or Anorexia Nervosa.

In order to be eligible, your patient must also meet additional criteria, detailed below. 

If unsure, consider referring the patient for an assessment privately, via psychiatry referral, or under a MHCP. The assessing clinician will advise your patient's diagnosis and eligibility for an EDMP.

DIAGNOSTIC CRITERIA:

  1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both:

    • Eating in a discrete period of time (e.g. within any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances

    • A sense of lack of control over eating during the episodes (e.g. a feeling that one cannot stop eating or control what or how much one is eating.

  2. Recurrent inappropriate compensatory behaviors to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

  3. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

  4. Self-evaluation is unduly influenced by body shape and weight.

  5. The disturbance does not occur exclusively during episodes of Anorexia Nervosa (in other words, the patient is not significantly below their expected body weight). 

In order to be eligible, your patient must also meet additional criteria, detailed below. 

If unsure, consider referring the patient for an assessment privately, via psychiatry referral, or under a MHCP. The assessing clinician will advise your patient's diagnosis and eligibility for an EDMP.

This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. 

EXAMPLES:

  1. Atypical Anorexia Nervosa: all of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.

  2. Bulimia Nervosa (of low frequency and/or limited duration): all of the criteria for Bulimia Nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/ or for less than 3 months.

  3. Binge Eating Disorder (of low frequency and/or limited duration): all of the criteria for Binge Eating Disorder are met, except that the binge occurs, on average, less than once a week and/ or for less than 3 months.

  4. Purging Disorder: Recurrent purging behavior to influence weight or shape (e.g.self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating.

  5. Night Eating Syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness of recall of the eating. The night eating is not better explained by external influences such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating disorder and or another mental disorder, including substance use, and is not attributable to another medical disorder or to an effect of medication.

In order to be eligible, your patient must also meet additional criteria, detailed below. 

From your assessment, it appears that your patient does not meet the criteria for an EDMP or you are unsure about their eligibility. On the following page, please consider referring them under a Mental Health Care Plan (MHCP), Chronic Disease Management Plan (CDMP), or Psychiatry referral for assessment, diagnosis, and opinion. 


At least 1 required for EDMP eligibility unless Anorexia Nervosa present

From your assessment, it appears that your patient does not meet the criteria for an EDMP or you are unsure about their eligibility. On the following page, please consider referring them under a Mental Health Care Plan (MHCP), Chronic Disease Management Plan (CDMP), or Psychiatry referral for assessment, diagnosis, and opinion. 


At least 2 required for EDMP eligibility unless Anorexia Nervosa present

From your assessment, it appears that your patient does not meet the criteria for an EDMP or you are unsure about their eligibility. On the following page, please consider referring them under a Mental Health Care Plan (MHCP), Chronic Disease Management Plan (CDMP), or Psychiatry referral for assessment, diagnosis, and opinion. 


In order to be eligible for an EDMP, your patient must complete the Eating Disorders Examination Questionaire (EDEQ). Once the patient has completed the EDEQ, please enter the global score at the bottom of the questionnaire in the field below. 

EDEQ global score >3 required to meet eligibility criteria.

From your assessment, it appears that your patient meets the criteria for an EDMP. If you are happy to provide the patient with this referral type, please bill MBS item #90250-90253 (more information on billing codes can be found here), and please ensure EDMP has been selected under "referral type" on the next page of this form.

From your assessment, it appears that your patient does not meet the criteria for an EDMP or you are unsure about their eligibility. On the following page, please consider referring them under a Mental Health Care Plan (MHCP), Chronic Disease Management Plan (CDMP), or Psychiatry referral for assessment, diagnosis, and opinion. 


Referral

Please select all that apply
Please provide any additional information specific to the psychiatry input required
Please specify how many sessions you're referring the patient for in the box to the left. Typically, EDMPs are referred in 4x courses of 10 sessions.
MHCP are referred in 2 courses for a total of 10 sessions (ie., 6 sessions then 4 sessions) EDMP are referred in 4 courses of 10 for a total of 40 sessions
Please specify how many sessions you're referring the patient for in the box to the left. Typically, EDMPs are referred in a single course of 20 sessions.
Up to 5 sessions under a CDMP with a dietitian Up to 20 sessions under a EDMP with a dietitian

Referral Information


Physical Examination

BMI  <13. 

Meets admission criteria.

0 0 1 2

Rapid weight loss. 

Meets admission criteria.

Rapid weight loss. 

Meets admission criteria.

please enter to the first decimal place.

Body temperature <35.5. 

Meets admission criteria.

Allow 1-2 minutes between lying and standing blood pressure measurements to ensure accuracy. 

Systolic BP <80pbm

Meets admission criteria.

Postural drop >20pbm

Meets admission criteria.

Allow 1-2 minutes between lying and standing pulse measurements to ensure accuracy. 

Pulse <50bpm

Meets admission criteria.

Postural tachycardia >20mmHg 

Meets admission criteria.

If any arrhythmia present or if prolonged QTc interval >450msec, consider medical admission.
If serum potassium <3.2mmol/L, serum Chloride <88mmol/L, or hypoglycemia noted, consider medical admission.
If the patient meets any of the criteria for medical admission, we are unable to accept the referral until they have been referred to the hospital emergency department and assessed for (and cleared of) the need for a medical admission (as per the Queensland Health guidelines for the medical management of eating disorders). Once they have been discharged or cleared from hospital, please upload a copy of the hospital discharge summary and send the completed referral along.
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Consent

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. I agree to continue monitoring and medically managing this patient medically whilst they are engaged in outpatient treatment.

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