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Insight Eating Insight Health
  • Home
  • Meet the team
  • Who we help
  • Services
    • Service Information
    • Services for HCPs
  • Contact
  • Blog

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We’re Here to Help – Self-Referral Form

Are you interested in accessing our services either for yourself or for someone else?
Please fill out the form below and we will get in touch as soon as possible.

Concerned about your data? Please see our Privacy Policy
Your Name(Required)
The person completing this form
(e.g. parent, partner, carer, clinician)

Important From this point on, all questions should be answered about the person this form is about, not you. Please provide their details, information, and experiences.

Have you been seen by IEIH before

If you have been seen by Insight before but are filling out the new referral form, please consider completing our Returning Clients Form. However, if your current issue differs from your previous concern, you are welcome to proceed as a new referral.

Contact Details

Name(Required)
Are you over 18?
If you are filling the form out for someone else, please refer to them.

Insight has age restrictions depending on the services that you need. We see ages 8+ for ARFID and 15+ for other eating disorders.

Address

Many thanks for contacting IEIH. A consultant will be in touch via text to discuss your enquiry. Please provide your preferred telephone number below.

Email(Required)
Are you a student living away from home?

Living away from home

Please provide some extra information

Home Address
Address for Place of Study

Insight Eating Insight Health Services (IEIH)

Is there a specific person at IEIH that you would like to see?
Are you happy to see someone online?
We try to accommodate everyone's preference for face to face or remote, however, due to availability and location we cannot always do this. If you have specific needs regarding this, please mention this in the box below.
Do you see any other health professionals about these issues?

How can we help?

Please click on the tab that most closely relates to why you would like support from IEIH

Our Services: Please select one or more

How can we help?

We understand that you might not be comfortable to input your height and weight. While it is not a requirement, this information helps us find the best care for you. It will not prevent you from being referred to one of our associates.
Please enter a number from 10 to 400.
This field is hidden when viewing the form
IEIH may think that you need a physical health check with your GP, would you be happy to do this?
IEIH requires everyone under the age of 18, where there is a concern with your physical health, to be seen by a GP to have their physical health monitored. Would you be happy with this?
How will you fund any sessions with IEIH?
If applying for funding, if you are not successful, are you willing to self-fund

This form will be reviewed and responded to within 7 days of completion. The form is secure and will only be read by a senior clinician within the IEIH team.

Please note that we are a service that does not work with individuals who have a high risk to their physical or mental health. We are not able to respond to crises.

If you need more urgent help, we suggest you contact your GP or go to A&E.

For immediate support please check NHS Crisis Services

Consent(Required)
Data will not be shared with advertising agencies or third parties. Data may only be shared with healthcare professionals (HCPs) with your express permission and solely for the purpose of providing treatment services. You can request access, correction, or deletion of your data at any time by contacting us and requesting removal.

Please see Privacy Policy

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