• New Patient Intake Form

    New Patient Intake Form

    Behavioral Nutrition Assessment
  • DOB*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What Type of support are you looking for?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you currently see a therapist?*
  • Format: (000) 000-0000.
  • Have you been deliberately trying to limit the amount of food you eat to influence your weight or body shape?*
  • Has thinking about food or eating made it very difficult to concentrate on things you are interested in?*
  • Have you tried to control your weight or shape by making yourself sick (vomit) or taking laxatives?*
  • Have you exercised in an excessive way as a means of controlling your weight?*
  • Do you feel out of control when you eat?*
  • Do you eat more rapidly than normal?*
  • Do you eat until feeling uncomfortably full?*
  • Do you eat large portions when not physically hungry?*
  • Do you eat alone because of feeling embarrassed?*
  • Do you find yourself having feelings of guilt or shame about your eating habits?*
  • Is this your first time seeking treatment?*
  • Are you Diabetic?*
  • Do you have a tendency to eat mindlessly?*

  • You will need recent blood work to schedule your intial assessment.

    please have your doctor's office fax the results to our office at 888-434-5097

  • IMPORTANT

    We require all new patients have EKG clearance from a cardiologist/physician if you have not already had one recently. Please have your doctor's office fax the results to our office. 888-434-5097
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