Norfolk and Suffolk NHS Foundation Trust - Suffolk CYP ARFID Team Consultation Request

Person Requesting Consultation

Your Name*

First Last

Your Organisation*

Your Service*

Your Job Role*

Please select your contact preference:*

What days/time is the most convenient for us to contact you?*

Your Contact Number*

Additional Number (if applicable) Optional Optional

Your Email Address*

Enter Email Confirm Email

Young Persons Details

Young Person’s Full Name*

First Last

Young Person’s Date of Birth*

Young Persons Stated Gender*

Young Persons Gender Identity Same At Birth?*

NHS Number Optional Optional

Consultation Information

Please provide a brief overview of your consultation request*

Please provide a brief clinical history & any relevant clinical information (including known/suspected differential diagnoses)*

Consent for Consultation

Has the parent/carer, or the young person (if aged 16 or above or considered Gillick competent), given informed consent for a consultation to take place?*

Is the young person aware of the consultation request?*

Check your answers

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