Refer yourself or a dependant to Schoen Clinic Chelsea

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

**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 questionnaire if you wish to access treatment at Schoen Clinic Chelsea. This allows us to gather some important initial clinical information upfront.

We treat children and adults with mental health conditions, including eating disorders on an outpatient basis.

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 (if possible) 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/the patient are clinically appropriate for treatment with us 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 to advise next steps.

Thank you for reaching out to us at Schoen Clinic Chelsea.

Private Enquiries Team
Schoen Clinic Chelsea

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):

Full patient address including postcode

Add full address here

GP name and surgery address including postcode

Full GP name

Surgery name

Add full address here

Pre-screening questionnaire

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

If yes, what is the diagnosis?

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

How long have you/the patient been experiencing such symptoms?

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?

Pre-authorisation code

Policy number

Name of insurer

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 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.

12. If the patient is under 18, are the CAMHS team currently involved? If so, please provide details of which CAMHS team. We will not contact them without consent to do so.

If so, please provide a summary

14. What is your/the patient's current alcohol intake? (please give approximate weekly units)

If so, please give basic details

If yes, when was the last time this occurred?

18. 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 or a dependant to Schoen Clinic Chelsea

Enquirer/patient information

Full patient address including postcode

GP name and surgery address including postcode

Pre-screening questionnaire

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