Clouds House Referral Form

Clouds House Referral Form
Submission Date

DayMonthYear
Time
Email Date Format

DayMonthYear
Email Sender
Are you completing this application on behalf of yourself?*

YesNo
Who are you completing this application on behalf of?*

EmployeeFamily memberFriendPartnerPatient

Information about you
Name*
What was your sex assigned at birth?

FemaleMaleI would prefer not to say
What do you use to describe your gender?*
Do you use pronouns?*
What are your pronouns?*
Other
Date of birth*

DayMonthYear
Ethnicity*
Preferred language*
Martial status *
Sexual orientation*
Home Address*

Street Address

Street Address Line 2

City / TownCounty

Postal CodeCountry
Housing situation*
Home telephone number

Area CodePhone Number
Mobile telephone number*
Email
Employment status*

Your family
Are you pregnant?*

YesNo
What is your expected date of delivery?

DayMonthYear
Do you have any children under your care?*

YesNo
Do you have any children under the age of 18 years old?*

YesNo
How many children do you have under the age of 18 years old? *
Do you have any children over the age of 18 years old?*

YesNo
How many children do you have over the age of 18 years old? *
How many children live with you?*

About your relationship with food
Do you feel that your relationship with food is a problem for you?*

YesNo
Please provide further information below*
Have you been diagnosed with an eating disorder?*

YesNo
Who made the diagnosis? *

First NameLast Name
Contact details*

If you are involved with other agencies
Are you receiving support from another organisation such as social services, mental health service, criminal justice team, substance misuse team?*

YesNo

Please enter information below
Professional's name

First NameLast Name
Agency
Telephone number

Please enter information below
Professional's name

First NameLast Name
Agency
Telephone number

If you are involved with other agencies

Continued
Do you have a care manager?

YesNo
Care manager name

First NameLast Name
Organisation
Email
Telephone number

Premature discharge planning
In certain situations, you may choose to conclude your treatment before your initially scheduled completion date, or the treatment team may determine that continued treatment is no longer suitable, often due to the breach of essential safety requirements. Regardless of the circumstances, your safety is our foremost concern, and we need some information to create a "premature discharge plan."
Will you be returning to your home address?*

YesNoOther
Please enter the address you plan to return to:
Address

Street Address

Street Address Line 2

City / TownCounty

Post CodeCountry
How will you get there?*

Public transportFamily memberFriendTaxiOther
Who should be contact in inform that you are being discharged from Clouds House.

Contact 1
Name*

First NameLast Name
Telephone Number*
Relationship*

Contact 2
Name

First NameLast Name
Telephone Number
Relationship

Paying for treatment
If you require assistance arranging payment, please contact the Admissions Department at Clouds House and a member from the team will do their best to advise you.
Please let us know how your treatment will be funded*

SelfFamilySignificant otherEmployerPrivate medical insuranceCare managerOther
Please provide further information*
How did you hear about Clouds House*

Finally
Is there anything else that you would like us to know about you?
Should be Empty: