Tier 1 screening form
Body Image Coach CIC provides Tier 1 psychoeducation and self-help around body image. This screen supports appropriate access and signposting and is not a clinical assessment, diagnosis or risk assessment.
Young person's name
Young person's age
What is the main reason for accessing the programme?
Is the young person currently receiving professional support for their mental health, eating difficulties, body image difficulties or wellbeing?
Is there a known or suspected eating disorder or mental-health condition? If there is, are you working with clinical services to monitor or treat this?
Are there any current safeguarding or immediate safety concerns? If yes, has this been referred to the appropriate professional/service?
Referrer Email
Referrer Phone
Your name and relationship to the participant?
Date
Month
Day
Year
Submit
Tier 1 Screening Form