Private patient pre-screening questionnaire

Please complete this pre-screening questionnaire to assess initial suitability for private treatment at Schoen Clinic Newbridge. We treat children and young people (8-18 years) with eating disorders as inpatients (residential), via our daycare programme (attend treatment during the day) and via outpatient appointments. Outpatient and daycare treatment is available for those aged 12-25 years.

Our specialised ARFID team also offer private ARFID assessments for children 8 years+ through to adults of all ages and this questionnaire can be completed for any patient requesting this diagnostic assessment.

There are 2 important stages to accessing private treatment with us; 1) complete this pre-screening questionnaire and 2) attend a full clinical assessment either online or in-person at our hospital if you/the patient is initially deemed appropriate for treatment with us following pre-screening.

If you/the patient are clinically appropriate and private funding is agreed, our aim is always to start treatment as soon as possible.

Once this questionnaire is complete and submitted, we will be in touch to update you regarding treatment suitability with us.

Thank you.

The Private Patient Care Team
Schoen Clinic Newbridge

Enquirer/patient information

Enquirer full name and title *

Contact telephone number *

Email address *

Confirm email *

Patient full name *

Patient date of birth *

Relationship to patient

Do you have legal authority to make this enquiry on behalf of the patient? (if under the age of 18 years) *

Pre-screening questionnaire

1. Has the patient been diagnosed with an eating disorder? *

2. If you/the patient does not have a confirmed diagnosis, what symptoms are you/the patient experiencing?

3. If there is no diagnosis yet, what stage is the patient at?

4. Please confirm the patient’s age as of today *

5. Can a GP or other healthcare professional referral be provided to give us the medical history we need? *

Please email referrals to newbridge.referrals@nhs.net

6. Are the CAMHS team currently involved? * If yes, please provide contact name and details:

7. Where is the patient currently? *

8. What is the patient’s approximate weight, height and BMI? *

9. Is private health insurance being used to fund treatment? *
If so, we will require the pre-authorisation code from the insurer in order to book a full treatment assessment.

If you are not using health insurance to fund treatment, please visit https://www.schoen-clinic.co.uk/birmingham/patients/self-funding-patients to ensure you are fully aware of our self-funding fees.

There is currently no charge for self-funding inpatient or daycare treatment assessments, which is the final stage to accessing private treatment with us.

10. Do you have the means to pay these fees in advance if you are not using insurance? *
We usually ask for a minimum of 3 weeks payment upfront and ongoing treatment is payable in advance.

11. We are located in Sutton Coldfield, will you be able to travel to us for treatment? *

12. Is the patient currently detained under the Mental Health Act? *
If yes, we can only accept the patient under the NHS treatment pathway. Please speak to the GP or CAMHS team for referral support.

13. Are you/your child consenting to this enquiry? *
We need this information to understand whether detention under the Mental Health Act is likely.

14. Do you/the child suffer from or been diagnosed with any other mental health condition or illness such as depression or anxiety? * If yes, please give basic details

15. Is there any other relevant information you would like us to know?

Data Privacy

Your personal information will be held securely by us and not shared with anyone outside of Schoen Clinic.

+44 121 580 8362

Private patient pre-screening questionnaire

Enquirer/patient information

Pre-screening questionnaire