Referral-first escalation sheet
RED-S Referral
Decision Guide
For coaches, parents, and athletic trainers
Use a calm, coach-safe escalation path when low energy availability signs stop looking isolated and start looking like a pattern.
Evidence-basedCoach-safeReferral requiredNot diagnosticCitations on sheet
The goal is fast support, not a debate over diagnosis.
Monitor + Support (Green)
A single soft signal with no clear performance drop or medical concern yet.
Action: reinforce fueling basics and watch for clusters instead of isolated moments.
Refer Soon (Yellow)
Two to three moderate clues or one clear health signal with training decline.
Action: refer this week and notify the athletic trainer or family now.
Pause + Refer Now (Red)
Bone pain, fainting, severe fatigue, or obvious restriction paired with health decline.
Action: stop the session and move to same-day medical support.
Risk Clusters
Fueling + Behavior
- Skipping meals, cutting carbs, or rigid food rules around training.
- Guilt around eating, fear of body change, or praise-seeking around restriction.
- Avoiding team meals or showing visible stress when fueling plans change.
- Compulsive extra training layered on top of the assigned work.
Health + Recovery
- Constant fatigue, slower recovery, or frequent illness.
- Missed periods, longer cycles, or delayed puberty milestones when relevant.
- Bone stress pain, repeat injuries, or unusual soreness that lingers.
- Low mood, irritability, or a sudden loss of spark around the team.
Escalation Clues
- Performance drop that continues even after normal recovery days.
- Rapid weight loss or obvious difficulty finishing normal sessions.
- Parent, trainer, or clinician concern already on the table.
- Multiple categories drifting together instead of one bad week.
Immediate Referral TriggersRefer to athletic trainer or physician today if you notice:
Bone pain or stress-injury history plus fatigue or cycle change
Rapid weight loss or visible restriction with a performance slide
Fainting, severe dizziness, or inability to finish easy training
Purging, compulsive exercise, or any immediate safety concern
What Not To Say
- Do not frame referral as punishment or a lack of toughness.
- Do not debate calories, weight, or appearance in the conversation.
- Do not promise the athlete they can keep training while serious signs are unresolved.
Coach Action Steps
- 1Name the pattern you are seeing instead of trying to prove the diagnosis.
- 2Document dates, symptoms, and who else is involved in the referral chain.
- 3Loop in the athletic trainer, parent or guardian, and sports medicine support early.
- 4Use private, factual language and remove the athlete from training when the pattern is urgent.