Eating Disorder Treatment Intake Form for Therapy and Nutrition Clinics
Eating Disorder Treatment Intake Form for Therapy and Nutrition Clinics
Screen for disordered eating behaviors, medical history, mental health comorbidities, and support systems prior to intake with a specialist treatment team.
This form includes sensitive questions. Please answer honestly; your responses are confidential.
Patient full name *
Your answer
Date of birth
Preferred pronouns *
Your answer
Contact email
Phone number
Emergency contact name and phone
Your answer
Who referred you?
Your answer
+ 16 more questions
About this template
Screen for disordered eating behaviors, medical history, mental health comorbidities, and support systems prior to intake with a specialist treatment team.
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