Eating Disorder Treatment Intake Form

Full Name Date of Birth Phone Number Email Address Address Contact Name Relationship Phone Number Current Diagnosed Medical Conditions Current Medications Psychiatric History History of Hospitalization Type(s) of Eating Disorder experienced Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Other Duration of Symptoms Current Symptoms/Behaviors Previous Treatment for Eating Disorder Your goals for treatment Support system (family, friends, etc.) Additional Comments