To: <<Addressee:Name>>
Date: <<Miscellaneous:Date (long)>>
Dear <<Addressee:Greeting>>
RE: <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB>>

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: <<Doctor:Name>>
Date: <<Miscellaneous:Date>>

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

GP DETAILS	
GP Name
Provider No.	<<Doctor:Name>>
<<Doctor:Provider Number>>	Practice Name & Address	<<Practice/Location:Name>>
<<Practice/Location:Address>>	
Practice Phone	<<Practice/Location:Phone>>	Practice Fax	<<Practice/Location:Fax>>	
GP Health Identifier	<<Doctor:HPI-I>>	
GP Email	<<Doctor:E-mail>>	

PATIENT DETAILS	
First Name (as on Medicare)	<<Patient Demographics:First Name>>	Last Name	<<Patient Demographics:Surname>>	
Preferred Name	<<Patient Demographics:Known As>>	Marital Status	<<Patient Demographics:Marital Status>>	
Date of Birth	<<Patient Demographics:DOB>>	Age	<<Patient Demographics:Age>>	
Gender Identity	As identified in software: <<Patient Demographics:Gender>>
Current identity (if different): <<Current identity (if different to birth gender) >>	
Address	<<Patient Demographics:Address>>	
Phone (h)	<<Patient Demographics:Phone (Home)>>	Phone (m)	<<Patient Demographics:Phone (Mobile)>>	
Cultural Identity	<<Patient Demographics:Ethnicity>>	Aboriginal or Torres Strait Islander	<<Patient Demographics:ATSI>>	
First Language	<<Patient Demographics:Language Preferred>> 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>>                               Ph: <<Support person contact no.>>
Pt consent to contact given: <<Pt consent to contact given>>    
Relationship to patient: <<Relationship to patient>>
Level of support:<<Level of support provided>>
Any information not to be shared with support person: <<Any information not to be shared>>
	
Relevant Current Medications	<<Clinical Details:Medication List>>	

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)  >>	
EDE-Q Global Score

InsideOut - EDE-Q online with scoring	<<EDE-Q Global score (=<3 to access EDP/Rebates)>>	
Eating Disorder Behaviours

(At least one needed to access EDP and rebates)	Eating disorder behaviours: <<Eating disorder behaviours (At least one needed)>> <<Second eating disorder behaviour>> <<Other>>
+Compensatory behaviours: <<+Compensatory behaviours>> <<Second compensatory behaviour>> <<Other>>
Frequency of behaviour: <<Frequency of behaviour>>	
Clinical Indicators 

(at least 2 to access EDP and rebates)	Clinical indicators: <<Clinical indicators (At least two needed)>> <<Second clinical indicator>>
Add detail as appropriate: <<Add detail as appropriate>>	
Access To EDP Established	<<Access to EDP established?>>	

MENTAL HEALTH ASSESSMENT & HISTORY	
Previous Specialist Mental Health Care	<<Any previous specialist mental health care>>	
Social & Family History	<<Clinical Details:Family History>>
<<Clinical Details:Social History>>	
Personal History

Childhood, education, relationship history, previous stressors	<<Personal history (Childhood, education, relations)>>	
Results of Mental State Examination

Detail findings

Royal Children’s Hospital Melbourne Mental State Examination Guide	Detail: <<Detail Mental State Examination results>>
Consider
Appearance: 
General behaviour:
Speech:
Mood:
Affect:
Thought:
Perceptions:
Cognition:
Insight:	
Risk assessment
Note any identified risks, including risks of self-harm 

Black Dog Institute resources	Identified risk: <<Any identified risk>>
Other: <<Detail any other risks>>	

Plan for managing risk: <<Plan for managing risk>>
Other: <<Detail any other plans>>	

MEDICAL REVIEW	
Examination

As indicated	Physical examination done: <<Physical examination done (As indicated)>>
☐ N/A
☐ Height, weight, BMI(adults) BMI percentile (children)
☐ Pulse & blood pressure, with postural measurements
☐ Temperature
☐ Assessment of breathing & breath (e.g. ketosis)
☐ Examination of periphery for circulation and oedema
☐ Assessment of skin colour (e.g. anaemia, hypercarotenaemia, cyanosis)
☐ Hydration state (e.g. moisture of mucosal membranes, tissue turgor)
☐ Examination of head & neck (e.g. parotid swelling, dental enamel erosion,       gingivitis, conjunctival injection)
☐ Examination of skin, hair and nails (e.g. dry skin, brittle nails, lanugo, dorsal finger callouses (Russell’s sign)
☐ Sit up or squat test (i.e. test of muscle power)

Investigations done: 
☐ FBC
☐ EUC/LFT/CMP/BSL
☐ Urinalysis
☐ Electrocardiography
☐ Iron studies, B12, folate
☐ E/P, LH/FSH, if appropriate TSH/PrI
☐ Bone densitometry – relevant after 9-12mths of disease or of amenorrhoea & as a baseline in adolescents. (Recommendation is for 2yrly scans thereafter while DEXA scans are abnormal)	
Observations: <<Clinical Details:Measurements (Selected)>>

Medical complications: <<Any medical complications>>

Psychological/ medical comorbidities: <<Any psychological/ medical comorbidities>>

Protective factors: <<Protective factors>>

Emergency Care/Relapse Prevention: <<Emergency Care/Relapse Prevention>>	
INITIAL TREATMENT RECOMMENDATIONS UNDER EDP	
Psychological treatment services (EDPT) (Initial 10 sessions)	Dietetic services
(up to 20 in 12 months)

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: <<Addressee:Name>>
Phone: <<Addressee:Phone>>
Goals: <<Goals for psychological treatment>>

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 indicated  (Name):>>
Phone: <<Dietitian ph.>>
InsideOut Treatment Services Database	Referred to: <<Psychiatrist/ Paediatrician details if known>>
Phone: <<Contact no:>>

Other team member
Profession: <<Other team member profession:>>
Name: <<Name:>>
Phone: <<Contact no.>>	
GP management – frequency of review:<<GP management – frequency of review>>
Actions for patient to take: ☐ Use of the Healthy Mind Platter   ☐ Read through RAVES approach
☐ Build my treatment team   ☐ Engage family/friends                ☐ Limit my exercise to set amount
☐ Attend all appointments with dietitian/psychologist                   ☐  Use Plate by Plate

Other actions identified by patient: <<Any actions for patient to take>>	
Patient education given: <<Patient education given?>> Specify: <<Specify>>	
Copy of EDP offered to patient: <<Copy of EDP offered to patient? (Consider triggers)>>	

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, <<Patient Demographics:Full Name>> (patient name - please print clearly)
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 <<Miscellaneous:Date>>

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 <<Doctor:Name>> Date <<Miscellaneous:Date>>