Phone Assessment Registration

Phone Assessment Registration

For the Recovered Living NZ Eating Disorder Programme
Welcome!

Thank you for considering the RLNZ programme in helping you or a loved one recover from an eating disorder. For more information on our programme, please head to www.recoveredlivingnz.com
Before going any further, we want to make sure that you or your loved one meets the preliminary criteria for our programme.

Please check that you can answer yes or n/a to the below questions.

Criteria*

	Yes	No	N/A
You are coming to our programme voluntarily
You are 16 or older if enquiring about our programme.
You are aware of our estimated programme cost projections detailed on our website and are able to meet these (our minimum length of stay is 4 weeks).
To the best of your knowledge you are medically stable (ie do not require hospitalisation)
Any dual mental health diagnoses are either manageable or stable (ie do not require psychiatric hospitalisation)
You are willing to keep yourself safe while in programme with us (we do not allow self-harm but we will support you if you have urges)
You are able to either eat solid food or complete liquid supplements - we do not tube feed at RLNZ
The RLNZ home is privately owned and therefore smoking or vaping is not allowed on the premises. If you smoke or vape, you are willing to use patches or abstain while in our programme.

Do you have diabetes?*

YesNo
Do you require insulin for your diabetes?

Yes I require insulinNo I do not require insulin
I am*

Seeking eating disorder treatment for myselfExpressing interest on behalf of someone else
Your Name

First NameLast Name
Your relationship to the person you are filling the form out for
Your Email Address
example@example.com
Demographic Information of Potential Client
Full Name*

First NameLast Name
Preferred name (if applicable) is: preferred name .
Pronouns
Current Age*
Email*
Cell*
Region*
Ethnicity*

New Zealand EuropeanMāoriSamoanCook Island MāoriTonganNiueanChineseIndianPrefer not to answerOther
I/the person I am enquiring on behalf of, is a New Zealand Resident or Citizen*

YesNo
I/the person I am enquiring on behalf of, is a resident/citizen of country .
Background Information
Briefly tell us why are you reaching out for treatment at this time.*
Have you (or the person you are enquiring on behalf of), received treatment for an eating disorder before?*

YesNo
Briefly describe the treatment, when was it, what was it, how long for, was it helpful or unhelpful?
Do you (or the person you are enquiring on behalf of) have any other mental health diagnoses or challenges other than an eating disorder?*

YesNo
What other mental health diagnoses or challenges do you have?
What do you want us to know and understand about you (or the person you enquiring on behalf of) in order to help you recover?
What questions do you have for us about our programme?
Thank you for taking the time to share with us.

Please select the 'Submit' button below. We will reach out to you via email within 2-3 business days to confirm we have received your registration for a phone assessment and to answer any questions you have. In this email we will give you an approximate wait time before we can book you in for an assessment.

The purpose of the assessment is to gather a detailed picture of your past and current situation in order to determine if our programme is right for you. This will also give you an opportunity to see how you feel about us.

If we both decide to go ahead, we will require you to undergo a medical stability clearance with your doctor prior to being accepted into our programme.

We look forward to talking with you soon!

The Recovered Living NZ Whānau.

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Phone Assessment Registration

Welcome!

Demographic Information of Potential Client

Background Information