Private patient pre-screening questionnaire

**If you are experiencing a mental health crisis, please contact your local crisis team or if you need urgent medical assistance, please dial 999.

If the above does not apply, please complete this pre-screening questionnaire to assess initial suitability for private treatment at Schoen Clinic Chelsea. We treat young people and adults with eating disorders and mental health conditions using a mixture of one-to-one appointments and group therapies (as recommended).

There are 2 important stages to accessing private treatment with us; 1) complete this pre-screening questionnaire and 2) attend an appointment at our welcoming London clinic so your dedicated expert can assess you fully and suggest the best course of treatment.

If you 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 with you as soon as possible.

Thank you.

The Private Patient Care Team
Schoen Clinic Chelsea

Enquirer/patient information

Enquirer full name (including title) *

Best contact telephone number *

Email address *

Confirm email address *

Patient full name *

Patient date of birth *

Relationship to patient (if you are not the patient)

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

Full patient address including postcode

Address line 1 *

Address line 2

Town *

County *

Postcode *

GP name and surgery address including postcode

Full GP name *

Surgery name *

Address line 1 *

Address line 2

Town *

County *

Postcode *

Pre-screening questionnaire

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

2. Have you/the patient been diagnosed with a mental health condition or eating disorder? *

3. If you/the patient does not have a confirmed diagnosis, what symptoms are being experienced?

4. Can you provide a GP or other healthcare professional referral to give us the medical history we need? *

(Please email this to – che-privateenquiries@schoen-clinic.co.uk)

5. Are any mental health professionals already involved? * If yes, please give name, practice name, best contact telephone number and email address:

6. Eating disorder patients only: What is your/the patient’s approximate weight, height and BMI?

7. 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. Please give the exact description from your insurer of what they have authorised (i.e. level of appointment - doctor or therapist and number of sessions)

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

8. Do you have the means to pay these fees in advance of treatment? *

9. We are located in Chelsea, London, will you be able to travel to us for treatment? *

10. Do you have any previous diagnosis of a mental health condition or eating disorder? * If so, please give basic details

11. Have you had any previous treatment for mental health conditions? * If so, please provide a summary

12. What is your current alcohol intake?

13. Do you smoke or use illicit substances? * If so, please give basic details

14. Have you ever experienced suicidal thoughts/ideations? * If yes, when was the last time this occurred?

15. Have you ever self-harmed? * If yes, when was the last time this occurred?

16. 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 20 3146 2300

Private patient pre-screening questionnaire

Enquirer/patient information

Full patient address including postcode

GP name and surgery address including postcode

Pre-screening questionnaire