By filling out this short form, you can reserve your spot in our treatment program and get started on the Admissions process. We will generally review your information and contact you within 24 hours of the date and time that you submitted it. All information provided on this admissions application form will remain strictly confidential.

Name

Name of Person Completing This Form

Last Name of Person Completing This Form

Your relationship to applicant

Self Family member/Other

Applicant First Name

Applicant's Date Of Birth

Applicant Last Name

Applicant's Gender

Male

Female

Applicant's Physical Address

Skip to another page if you are an applicant

Street address

City

State

ZIP code

Country

Confidential Information

Please provide a telephone number and email address to which we may communicate confidential information regarding the patient's care.

Phone#

Preferred Email Address

Demographic Information

American Indian or Alaskan Native Black or African American Asian Native Hawaiian or other Pacific Islander White – Non-Hispanic White – Hispanic Latino/Latina Other Race/Ethnicity of the applicant (check all that apply):

Religious Preference of the applicant (check all that apply):

Jewish Muslim Christian - Catholic Christian – Protestant Buddhist Hindu Atheist Agnostic None Other

Do you identify as (check all that apply):

Straight female Straight male Gay male Lesbian Bisexual male Bisexual female Unsure/Questioning sexual orientation Transgendered

Health Information

Do you/applicant outwardly express thoughts or feelings that you/applicant is “fat” or obese?

Yes No

Current height

Current Weight

Weight approx. 2 years ago

Weight approx. 1.5 years ago

Weight approx. 1 year ago

Weight approx. 6 months ago

Behavioral Information

Briefly stated, why are you seeking treatment at this time?:

Do you/applicant outwardly express thoughts or feelings that you/applicant is “fat” or obese?

Yes No

To the best of your knowledge, answer the questions below about your/applicant's behavior. Please answer with the following scale — Often (3 or more times per day), Sometimes (4-5 times per week), Rarely (a few times per month), Never to my knowledge (to your knowledge)*

1. Am terrified about being overweight.

Often Sometimes Rarely Never

3. Find myself preoccupied with food.

Often Sometimes Rarely Never

5. Cut my food into small pieces.

Often Sometimes Rarely Never

7. Particularly avoid foods with high carbohydrate content (e.g. bread, potatoes, rice, etc.).

Often Sometimes Rarely Never

9. Vomit after I have eaten.

Often Sometimes Rarely Never

11. Am preoccupied with a desire to be thinner.

Often Sometimes Rarely Never

13. Take longer than others to eat my meals.

Often Sometimes Rarely Never

15. Feel that food controls my life.

Often Sometimes Rarely Never

17. Feel that others pressure me to eat.

Often Sometimes Rarely Never

19. Feel uncomfortable after eating sweets.

Often Sometimes Rarely Never

21. Like my stomach to be empty.

Often Sometimes Rarely Never

2. Avoid eating when I am hungry.

Often Sometimes Rarely Never

4. Have gone on eating binges where I feel that I may not be able to stop.

Often Sometimes Rarely Never

6. Aware of the calorie content of foods that I eat.

Often Sometimes Rarely Never

8. Feel that others would prefer if I ate more.

Often Sometimes Rarely Never

10. Feel extremely guilty after eating.

Often Sometimes Rarely Never

12. Am preoccupied with the thought of having fat on my body.

Often Sometimes Rarely Never

14. Avoid foods with sugar in them.

Often Sometimes Rarely Never

16. Display self control around food.

Often Sometimes Rarely Never

18. Give too much time and thought to food.

Often Sometimes Rarely Never

20. Engage in dieting behavior.

Often Sometimes Rarely Never

22. Have the impulse to vomit after meals.

Often Sometimes Rarely Never

Description Of Behaviors

Please describe the current and past restrictive behavior:

Please describe the current and past binging behavior:

Please describe the current and past purging by vomiting behavior:

Please describe type and frequency of exercise:

Please describe current and past laxative or diuretic use:

Do you/applicant have any food allergies?

Yes No

Do you/applicant have any food rituals around eating meals or snacks?

Yes No

How long have you/applicant struggled with food, body weight, body shape, body size, or body appearance?

Less than 6 months 6-12 months 1-2 years 2-3 years Other

Behavioral Interference

Please indicate the extent to which your/applicant's eating behaviors interfere with the following:*

School or Work:

Never Rarely Sometimes Often Always

Personal Hygiene:

Never Rarely Sometimes Often Always

Family Relationships:

Never Rarely Sometimes Often Always

Friendships:

Never Rarely Sometimes Often Always

Self-Esteem:

Never Rarely Sometimes Often Always

Finances (personal or familial):

Never Rarely Sometimes Often Always

Intimate Relationships:

Never Rarely Sometimes Often Always

Health:

Never Rarely Sometimes Often Always

Please list any other activities with which the you/applicant's eating behaviors have interfered:

Daily Routine

Please provide an example of the you/applicant's typical food choices and his/her typical schedule. Include meal times, food selections, and approximate amount eating. Please also note episodes of binging, purging, exercise, and/or restricting. Please provide an answer for all questions below, even if the descriptor is "N/A".

Wake Up

Breakfast

Snack 1

Lunch

Snack 2

Dinner

Snack 3

Bedtime

During Normal Sleeping Hours:

Symptoms

Are you/applicant currently engaged in behaviors of hiding, sneaking, or stealing food?

Yes No

Please indicate any other eating disorder symptom(s) not adequately detailed in this form:

Substance Use

To your knowledge, please indicate if the child has engaged in the illicit use of any of the following substances. If none of these, please respond by checking "not currently using."*

Benzodiazepines: