<AdrDetails>
Date: <FormattedDate>
Dear <AdrGreeting>
RE: <PtFullName>	DOB: <PtDoB>

Please find below an Eating Disorder Care Plan (EDP) prepared for this patient with details of their condition. This referral cover sessions 1-10 for psychological intervention, 1-20 for a dietician, after which I will review and provide ongoing referrals as appropriate. Many thanks for your care and for your ongoing collaboration and communication.

Yours sincerely,

Name: <DrName>	Date: <TodaysDate>

GP EATING DISORDER PLAN (EDP)
Item No: 90250 – 90257 	MBS Quick reference

GP DETAILS	
GP Name
Provider No.	<DrName>
<DrProviderNo>	Practice Name & Address	<Practice>
<UsrAddress>	
Practice Phone	<UsrPhone>	Practice Fax	<UsrFax>	
GP Health Identifier	<DrHPII>	
GP Email	<DrEmail> GP Ph. <DrPhone>	

PATIENT DETAILS	
First Name (as on Medicare)	<PtFirstName>	Last Name	<PtSurname>	
Preferred Name	<PtPrefName>	Marital Status	<PtMaritalSt>	
Date of Birth	<PtDoB>	Age	<PtAge>	
Gender Identity	Birth sex: <PtSex>
Gender identity: <GenderIdentity>	
Address	<PtAddress>	
Phone (h)	<PtPhoneH>	Phone (m)	<PtPhoneMob>	
Cultural Identity	<PtEthnicity>	Aboriginal or Torres Strait Islander	 Yes   No	
First Language	                                                   Interpreter needed?        	
Family/Support Person Details (Consider involving support person in session if appropriate)

InsideOut resources for carers
Butterfly resources for carers
NEDC resources for carers	Preferred support person: <Preferred support person name> Ph: <Phone:>

Pt consent to contact given: <Patient consent to contact given?>    

Relationship to patient: <Relationship to patient>
Level of support provided: <Level of support provided> 

Any information not to be shared with support person: <Any information not to be shared with support person> 
	
Relevant Current Medications	<SelectedRx>	

ESTABLISH ACCESS TO EDP (If not appropriate consider using a MHCP or GPMP)	
Eating Disorder Diagnosis (DSM-V) 

InsideOut GP Hub – diagnostic guidelines	<Eating Disorder Diagnosis (DSM-V)                                              Diagnostic guidelines and information:  https://gp.insideoutinstitute.org.au/>	
EDE-Q Global Score

InsideOut - EDE-Q online with scoring	<EDE-Q Global Score  (Greater than or equal to 3 to access EDP for BN, BED, OSFED)                                                             EDE-Q online:  https://insideoutinstitute.org.au/assessment/?started=true>	
Eating Disorder Behaviours

	Eating disorder behaviours: <Eating disorder behaviours (At least one needed to access EDP and rebates for BN, BED, OSFED)>

+Compensatory behaviours: <Detail any compensatory behaviours>
Other: <Other compensatory behaviours>
Restiriction type: <Restriction type (If relevant)>	
Clinical Indicators 

	Clinical indicators: <Clinical indicators (At least 2 needed to access EDP and rebates for BN, BED, OSFED)>
Add detail as appropriate: <Add detail as appropriate>	
Access To EDP Established	<Access To EDP Established (If no, consider Better Access to Mental Health Plans)>	

MENTAL HEALTH ASSESSMENT & HISTORY	
Previous Specialist Mental Health Care	<Any previous Specialist Mental Health Care>	
Social & Family History	<SocialHx><FamilyHx>	
Personal History

Childhood, education, relationship history, previous stressors	<SelectedPMH>
Other personal Medical history:
<Ix>	
Results of Mental State Examination

Detail findings

Royal Children’s Hospital Melbourne Mental State Examination Guide	<Mental State Examination Includes:>
<Detail MSE findings.                                                              Royal Childrens Hospital guidelines:  https://www.rch.org.au/clinicalguide/guideline_index/mental_state_examination/>	
Risk assessment
Note any identified risks, including risks of self-harm 

Black Dog Institute resources	Identified risk: <Identified risk>
Other: <Other identified risk>	
	Plan for managing risk: <Plan for managing risk>
Other: <Other plan for managing risk>	

MEDICAL REVIEW	
Examination

As indicated	Physical examination done: <Physical examination done (As indicated)>

Investigations done: <Investigations done (As indicated)>
	
Observations: <Observations> 

Medical complications: <Detail any medical complications>

Psycological/ medical comorbidities: <Detail any psychological/ medical comorbidities>

Protective factors: <Detail any protective factors>

Emergency Care/Relapse Prevention: <Emergency Care/Relapse Prevention plan>	
INITIAL TREATMENT RECOMMENDATIONS UNDER EDP	
Psychological treatment services (EDPT) (Initial 10 sessions)
Find a provider:
InsideOut Treatment Services Database	Dietetic services
(up to 20 in 12 months)
Find a provider: Connect.ed

Dietitian to provide letter of treatment to GP on completion	Psychiatric/paediatric review

Assessment by psychiatrist/ paediatrician required for patient to access EDPT sessions 21-40	
Referred to: <AdrName>
Phone: <AdrPhone>
Goals: <Psycological treatment goals>
Psychological treatments allowed under EDP (to be determined together with MH professional):
•	Family based treatment, Adolescent focused therapy, CBT, CBT-AN, CBT-E, SSCM for AN, MANTRA for AN, IPT for BN or BED, DBT for BN or BED, Focal psychodynamic therapy for EDs	Referred to: <Referred to dietitian (if relevant) name>
Phone: <Phone>

	Referred to: <Referred to psychiatric/paediatric specialist (If known) name>
Phone: <Specialist Phone>

Other team member
Profession:
Name:
Phone: 	
GP management – frequency of review: <GP management – frequency of review>
Actions for patient to take: <Actions for patient to take>
Healthy Mind Platter
RAVES
Plate by Plate
Other actions identified by patient: <Other actions identified by patient>	
Patient education given: <Patient education given> Specify: 	
Copy of EDP offered to patient: <Copy of EDP offered to patient (consider removing triggering content)>	

GP REVIEW REQUIREMENTS	
Mental health: Prior or at sessions 10, 20 & 30 of psychological treatment & at EDP completion
Dietetics: At EDP completion
Note: PSYCHIATRIC OR PAEDIATRIC REVIEW
Required in addition to GP review to access sessions 21-40. Consider referring early in course of treatment.	

RECORD OF PATIENT CONSENT	
I, <PtFullName> agree to information about my mental and medical health to be shared between the GP and the health professionals to whom I am referred, either via correspondence, verbal communication, or case conferences to assist in the management of my health care. 

Signature (patient)                                   Date <TodaysDate>

I (GP) have discussed the proposed referral(s) with the patient and am satisfied that the patient understands the proposed uses and disclosures and has provided their informed consent to these.

GP Signature                                           GP Name <DrName> Date <TodaysDate>