Contact

Please complete the self-referral form. All details you provide will remain confidential. I look forward to hearing from you.

Please read the Frequently Asked Questions page for details regarding fees and eligibility for treatment.

I am completing this form for

Client Name

First Name

Last Name

Client Ethnicity

Preferred Pronouns

Client Age

Client Date of Birth

YYYY

Client Location

Where in NZ is the client based?

Phone

(###)

###

####

Referrer Details

If you are completing this form for someone else

GP Name and Practice

Summary of Concerns

Briefly describe what you'd like support with

Prior Treatment (if any)

Any particular reason for seeking help at this time?

Is there anything else you would like to share?

Please confirm you meet the following eligibility criteria:

Age is over 18 years BMI is above 17 No hospitalisations in past 6 months due to eating disorder or psychiatric risk

Yes

How did you hear about this service?