Private patient pre-screening questionnaire

Please complete this pre-screening questionnaire to assess initial suitability for private treatment at Schoen Clinic York. We treat adults (18 years+) with eating disorders as inpatients (residential), via our daycare programme (attend treatment during the day) and via outpatient appointments.

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 are initially deemed appropriate for treatment with us following pre-screening.

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 to update you regarding treatment suitability with us.

Thank you.

The Private Patient Care Team
Schoen Clinic York

Enquirer/patient information

Enquirer full name (including title) *

Contact telephone number *

Contact email address *

Confirm email *

Full name of patient (including title) *

Patient date of birth *

Do you have legal authority to make this enquiry on behalf of the patient if you are not the patient? *

If you are not the patient, what is your relationship to the patient?

Pre-screening questionnaire

1. Have you/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. Please confirm your/the patient’s age as of today *

4. Can you provide a GP or other healthcare professional referral to give us the medical history we need? *
(Please email this securely to - schoenclinicyork.referrals@nhs.net)

5. Where are you/the patient currently? *

6. What is 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 the full treatment assessment.

If you are not using health insurance to fund treatment, please visit https://www.schoen-clinic.co.uk/york/patients/private-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.

8. Do you have the means to pay our fees in advance? *
We usually ask for a minimum of 3 weeks payment upfront and ongoing treatment is also payable in advance.

9. We are located just outside of York city, will you be able to travel to us for treatment? *

10. Are you/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 for support with referral.

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

Have you ever tried to take your own life? * If so, how?

From a risk perspective, have you ever ligatured? *
This is a very important question related to the nature of our hospital environment.

12. 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 1904 404400

Private patient pre-screening questionnaire

Enquirer/patient information

Pre-screening questionnaire