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Referrer details
Full name
Role / professional title
Organisation / clinic name
Contact email*
Contact phone number
Are you the client’s primary care provider?
Yes
No
Client information
Full name
Age
Date of birth
Gender (optional)
Contact email*
Contact phone
Name of parent/guardian (if under 18)
Contact of parent/guardian
Has the client consented to this referral?
Yes
No
Presenting concerns
Please describe the reason for referral
Has the client been formally diagnosed with any of the following?
ADHD
Autism / AuDHD
ARFID
Eating disorder
Other neurodevelopmental or mental health condition
Are any of the following currently concerns? (tick all that apply)
Emotional eating or binge eating
Appetite loss (general or medication-related)
Highly selective or restrictive eating
Meal refusal
Sleep issues
Suspected nutrient deficiency
Suspected thyroid imbalance or blood sugar dysregulation
Texture or sensory-based food refusal
Low energy / fatigue
Poor growth / weight loss
Interoceptive awareness difficulties
Anxiety around food / mealtimes
Executive dysfunction affecting eating
Medical and nutritional background
Known allergies or intolerances
Current medications (particularly stimulants or SSRIs)
Any recent blood test results available
Relevant medical history or co-occurring conditions
Other professionals involved in care (e.g., CAMHS, dietitian, OT, SLT)
Referral context
What outcome are you hoping nutritional therapy could support?
Is this referral being made as part of a multidisciplinary approach?
Yes
No
Is the referral self-funded or supported by another organisation?
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