Eating Disorders QLD

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PRIVACY, CONSENT AND ELIGIBILITY

I understand that the information I provide on this form will be stored on a secure database and shared within the EDQ team, as necessary

To determine eligibility for EDQ’s funded services, are you an Australian citizen or permanent resident?

Yes

Due to the high demand for EDQ's funded services, and allowing for fair equitable distribution of therapeutic resources to the community:

• EDQ requires 48 working hours notice of cancellation for all appointments

• In the event of 3 late cancellations or no-shows, your practitioner will discuss other support options with you before booking another appointment

EDQ acknowledges recovery and the therapeutic process is not linear. Please discuss any changing needs or barriers with your practitioner so EDQ can best support you and the greater community.

We will email you a written Consent and Rights & Responsibilities Form for you to review and sign before your Intake Appointment. These documents detail how we handle your information. If you have any queries, feel free to ask any staff member.

To access services with EDQ, you do not need a diagnosis. However, we do require that you engage regularly with a GP to monitor your medical stability. As part of this process, a GP will need to sign EDQ’s client Medical Clearance form. Medical monitoring is required for all clients, no matter what kind of eating disorder behaviour is present. Eating disorders have significant impacts on physical health. If you do not currently have a suitable GP, please let us know and we can assist you to find one.

I will engage regularly with a GP for the purposes of monitoring my medical stability and acknowledge that as a part of this process, a GP will need to sign EDQ’s Medical Clearance form at a minimum of every 12 months.

Yes

How often do you currently engage with your GP?

GP name

GP practice

GP phone

GP email

Do you consent to EDQ contacting your GP and providing them with our Medical Clearance form?

Yes

Referring Clinician Details (if applicable). Please note that a referral is not required to engage with EDQ services.

Referring clinician name

Referring clinician role

Referring clinician Organisation/HHS/EDSS

Referring clinician phone

Referring clinician email

Referring clinician discharge summary

Referring clinician additional notes:

CONSENT TO EVALUATION, RESEARCH AND REPORTS/PUBLICATIONS

EDQ may use client data collected to undertake program evaluations of EDQ services for the purpose of maintaining standards or identifying areas for improvement, as well as to report program outcomes to funding bodies or public forums (e.g. conferences or published papers/reports). Client data that may be used for this purpose can include demographic information, outcome data (e.g. results on psychometric instruments such as the DASS-21, EDE-Q, RAS-DS, or K10), client feedback and service participation data (e.g. the type and number of services participated in). Any data analysed for this purpose will be de-identified and will only ever be published in a non-identifiable or aggregate form. I consent to my client data being used for evaluation and research purposes and understand that the outcomes of evaluation and research may be published in places that are accessible to the public. I understand that if I do not consent to my client data being used for evaluation and research purposes, it still may be used for mandatory reporting of service delivery to funding bodies. I understand that I can modify my consent to evaluation and research at any time. I understand that if I modify my consent, any previous reports/publications may not be able to be modified.

Yes

I would like to discuss this further during my intake

PERSONAL DETAILS

Title

Family name

Given name(s)

Preferred name:

How would you describe your gender?

Pronouns

Date of Birth

Mobile

CURRENT ADDRESS

Street address

Suburb

Postcode

ACCESSIBILITY

What is your proficiency in English?

Do you require an Interpreter/Auslan Connections and/or advocacy service?

Yes, please specify language

Interpreter language

Do you need the use of assistive technology?

Yes, please specify

Assistive technology

Do you have any current literacy/reading issues that you might need assistance with?

Yes

Are you a current NDIS participant?

Yes

DEMOGRAPHICS

Country of birth

Are you of Aboriginal or Torres Strait Islander Origin?

What cultural background or ethnicity do you identify with?

What is the main language spoken in your home?

Do you identify with the LGBTIQIAP+ community?

Yes

Prefer not to answer

What is your employment status?

Other employment status

What is your main source of income?

Other source of income

What is your marital status?

FAMILY AND CARER SUPPORT

Do you have a family member/friend/partner supporting you with your eating disorder?

Yes

You can invite a support person to your intake appointment if you would find that helpful – just let us know when we book that appointment in. Additionally, EDQ’s Carer & Key Support Team have a range of services and support options for family members, carers and key support people who are supporting a loved one with an eating disorder. Your carers or key supports can contact EDQ directly at admin@edq.org.au to find out more information and/or access this support.

Emergency contact name

Emergency contact relationship

Emergency contact phone

Emergency contact email

EATING DISORDER PRESENTATION/HISTORY

In approximately which year did you first experience any eating disorder symptoms, including significant concerns about weight and shape?

When did you first reach out for any support for your eating disorder? (This can be any health professional- it could be your GP, your school counsellour or nurse etc)

Please indicate any diagnosis that you have been given

Other diagnosis

Who was the diagnosis made by?

Diagnosis made by other professional

When was your first contact with specialist eating disorder treatment/services? (This might be EDQ, QuEDS, a psychologist, dietitian etc. - someone who specifically works with eating disorders)

What support have you accessed so far for your Eating Disorder(s)?

Other supports accessed

EDQ SERVICES

Which EDQ services are you interested in?

ADDITIONAL INFORMATION

How did you hear about EDQ?

EDQ strives to be inclusive of diverse groups (Aboriginal and Torres Strait Islander peoples, Culturally and Linguistically Diverse (CALD), religious / spiritual beliefs, gender, sexual orientation, physical and intellectual disability, age and socio-economic status), that access the service. Please let us know if you have any requirements related to this statement, or would like to be given information on other available services that you could also connect with?

Is there anything else you would like EDQ staff to be aware of when contacting you?