Weight Management and Eating Disorder Recovery

Intake Form

To schedule a session, please fill out the form below or give me a call. Family or couple sessions are available upon request. Please note, three days prior to our first session, please fill out the intake form below. All information is confidential.

If you only have a cell phone number, please enter that number.

Medical History

Have you ever had any of the following health problems? Please place an “x” in all fields that apply: If available, please write the values in each field. Any actual medical records and/or lab values from your doctor would be very helpful as well.

Weight History

Lifestyle Questionnaire

Please answer the following questions as thoroughly as you like, the clearer the better! Answer questions the best you know how. If you are not sure how to answer any of them, just do what you can. We will look over your responses together and make changes if necessary.

Looking to the future

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