To: <AdrName>
Address: <AdrAddress>
Date: <FormattedDate>
Dear <AdrGreeting>
RE: <PtFullName> 				DOB: <PtDoB>

Please find below an Eating Disorder Care Plan Review prepared for this patient with details of their condition. This referral covers sessions <This referral covers sessions:>. Many thanks for your continuing care and for your ongoing collaboration and communication.

Yours sincerely,

Dr Name: <DrName>
Date: <TodaysDate>

GP EATING DISORDER PLAN REVIEW (EDP Review)
Item No: 90264               MBS Quick reference                      

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

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: ☐ Yes     ☐  No	
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 no.>
Pt consent to contact given: <Pt 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>	

GP REVIEW	
GP Review time point: <GP Review time point>	
Eating Disorder Behaviours	Continuing behaviours <Continuing ED behaviours>
Other: <Other behaviours> 
Restriction type (If relevant): <Restriction type (if relevant)>
Other: <Other restriction type>
Compensatory behaviours (If relevant) <Compensatory behaviours (if relevant)>
Other: <Other compensatory behaviours>
Behaviour frequency: <Compensatory behaviour frequency>	
Risk assessment 

Note any identified risks, including risks of self-harm and harm to others

Blackdog resources	Identified risk: <Any identified risk>
Other: <Other identified risk>
Plan for managing risk: <Plan for managing risk>
Other: <Other plan for managing risk>	
Observations	<Observations>	

REVIEW TREATMENT RECOMMENDATIONS UNDER EDP	
Psychological treatment services (EDPT)  
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>
Progress review/comments: <Progress review/comments to referree>	Referred to: 
Phone:

Progress review/comments: 	Referred to:
Phone:

Comments:

** For review  at session 20 only: 
Does specialist review (psychiatry/ paediatrics) support additional sessions 21-40?
<If at session 21 does specialist review (psychiatry/ paediatrics) support additional sessions 21-40?>
Specialist letter attached: <Specialist letter attached> 	
Emergency Care/Relapse Prevention: <Emergency Care/Relapse Prevention plan                             Management supports: https://gp.insideoutinstitute.org.au/> 
InsideOut GP Hub – Management supports

GP management – frequency of review/monitoring: <GP management - frequency of review/monitoring>
Actions for patient to take: <Actions for patient to take>    
Healthy Mind Platter  
RAVES
Plate by Plate
Other: <Other actions for patient>
	
Additional 10 EDPT sessions recommended	<Additional 10 EDPT sessions recommended?>	
Copy of EDP Review offered to patient	<Copy of EDP Review offered to patient? (consider removing any triggering content)>	
Physical examination conducted 	<Physical examination conducted?                                         Reccomendations: https://gp.insideoutinstitute.org.au/>	

EATING DISORDERS PATIENT PHYSICAL ASSESSMENT
	
Suggested minimal physical assessment 	Height, weight, body mass index (BMI; adults), BMI percentile for age (children)
Pulse and blood pressure, with postural measurements
Temperature	
Any significant findings/comments	<Any significant findings/comments?>	

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>