Refer yourself to Schoen Clinic York

Complete this private patient pre-screening questionnaire at any time to suit you.

Please complete this questionnaire if you wish to request private treatment at Schoen Clinic York. This allows us to gather some important initial clinical information upfront.

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) send a recent GP or healthcare professional referral/clinical summary so we have some medical information to hand. Once we have this information, we will share it with our in-house clinical teams and advise how we can best help.

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

We look forward to hearing from you.

Best wishes

Private Enquiries Team
Schoen Clinic York

Enquirer/patient information

Enquirer full name (including title)

Best contact telephone number

Best contact email address

Patient full name

Date of birth

Relationship to patient (if you are not the patient)

Pre-screening questionnaire

If yes, what is the diagnosis?

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

3. Please confirm your/the patient’s age as of today

5. Where are you/the patient currently?

6. What is your/the patient’s approximate weight, height and BMI?

Pre-authorisation code

Policy number

Name of insurer

If you are not using health insurance to fund treatment, please visit our website to ensure you are aware of our self-funding fees.

We ask these questions for clinical reasons but please be assured, we keep all answers securely held on our systems.

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.

If yes, please give basic details.

If so, how?

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

Data privacy: I have read and understand the Privacy Policy

Thank you for completing our private pre-screening questionnaire, a member of our friendly team will be in touch as soon as possible.

Conditions

Therapies

Refer yourself to Schoen Clinic York

Enquirer/patient information

Pre-screening questionnaire

Quick links

Conditions

Therapies

Refer yourself to Schoen Clinic York

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Enquirer/patient information

Pre-screening questionnaire

Quick links