Request for Consultation

Dear Health Professional,

A range of tasks can be requested as part of case consultations and we request you be specific in your request in the form below.

Examples of tasks for case consultation include: case review; care team & service system planning and coordination; physical risk: care planning; assessment/management; case management in eating disorders; comprehensive treatment planning; inpatient management; client readiness for change and engagement; assessment and management of specific symptoms; accessing other services; carer support and treatment.

Before proceeding with your request please ensure you read and can agree with the following privacy and clinical responsibility positions regarding case consultations.

Privacy Note

Information about your patient or client provided with this form and during the course of a consultation may be provided in de-identified form, to protect the privacy of your patient. However, information you provide may directly, indirectly or inadvertently disclose information about your patient or client, which may identify them. Information regarding patients who may reasonably be identified from that information is subject to the Health Records Act 2001 (Vic) and Privacy and Data Protection Act 2014(Vic).

If it is likely the disclosed information will identify your patient or client, you should obtain the consent of your patient or client prior to discussing their case with CEED. Information you provide (whether or not that information identifies your patient or client) will be kept confidential by CEED as required by law.

Position of CEED on Clinical Responsibility for Patients

In the course of a secondary consultation, CEED consultants may provide information, advice and recommendations based on the clinical information you provide. Whilst every effort is made to provide accurate and pertinent information and advice, any information or advice provided by CEED is necessarily based on the clinical information you provide. We do not independently verify that information. Accordingly, you are required to evaluate our advice and recommendations for application in the specific circumstances of your patient.

CEED emphasises that the purpose of the secondary consultation is to provide you, the treating health professional, with advice and assistance regarding the identification, treatment and management of eating disorders. The patient in respect of whom the consultation is sought remains your patient, and responsibility for the ongoing clinical care of the patient remains with you at all times and CEED does not assume any responsibility for the treatment of your patient.

We look forward to working with you.

Clinical Team
Victorian Centre of Excellence in Eating Disorders

NAME: *

POSITION: *

Area Mental Health Service you work in (AMHS, CAMHS, CYMHS) - If not one of these services, please provide details in "Other Organisation" text box below:

AMHS Program/Department/Team:

Professional Group/Discipline:

Other Organisation:

PHONE NUMBER: *

MOBILE NUMBER:

EMAIL: *

TYPE OF REQUEST: *

Primary Case Consultation (collaborative assessment of client with CEED clinician)

Secondary Case Consultation (case discussion consultation with CEED clinician)

Carer Consultation (Carer Consultant and CEED clinician to come and see family and clinician)

Client information - Gender: *

Female

Male

Other

Client information - Age: *

Client information - Resident Suburb / Town: *

Client information - Diagnosis (can select more than one): *

CARE TEAM: Other Agencies/Professionals involved in care/treatment:

Brief outline of the client’s clinical presentation (please include weight, height & BMI; recent weight trend): *

Brief outline of the mental health treatment approach and formulation: *

Brief outline of the client's family background and structure: *

Brief outline of the client's social, school/work history and current circumstances: *

Please outline the issues you would like support or help with: *

Please select up to 3 areas of focus for consultation *

CEED is very interested to learn how useful and beneficial our consultation services and processes are for the individual and teams requesting consultation, the service system and to clients. To help CEED gain feedback on the consultation, please complete the rating scales below. You will be requested to complete Post-Consultation rating scales at the end of the consultation process.

I have read and agree with the CEED policy regarding privacy and clinical responsibility for patients as outlined in the Introduction. *

Yes

No

After previewing, please make sure you click submit. You should receive an automated response saying your form has been submitted and we also respond with an email acknowledging we have received your request. If you do not receive one or both of these within 48 hours, please contact us directly to check request was submitted.

Request for Consultation

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