Apply for a befriender

Please complete this form if you would like to apply for a befriender. All information provided is treated confidentially.

Your details

Name

Date of birth

Address line 1

Address line 2

Town

County

Postcode

Email address

Telephone number

About your eating problems

How would you describe your eating problems and the difficulties you have been experiencing?

How long have you been experiencing these difficulties?

Have you had a diagnosis of an eating disorder? If yes, what is your diagnosis?

Are you currently receiving treatment from any healthcare professionals (NHS or private) in relation to your eating problems? If so, please state what treatment (e.g. CBT, counselling)

Do you have a BMI of 17 or over?

(please be honest)

Yes

No

Thank you for your time and courage in completing this form. We will be in touch shortly via email to arrange a phone chat about the befriending service.

Permission

By completing this form you agree that we can use your contact details to respond to your enquiry, and agree to the use of your data as outlined in our privacy policy.