Eating Disorders Initial Assessment Intake Form
Personal Information
First Name
Last Name
Date of Birth
Age
Gender
Phone Number
Email Address
Address
Emergency Contact
Name
Relationship
Phone Number
Referral Information
Referred By
Reason for Referral
Presenting Concerns
Describe your current concerns with eating, weight, and shape
Eating Disorder Symptoms & History
How long have you been experiencing these concerns?
Have you been previously diagnosed with an eating disorder?
Please list any specific behaviors (e.g., restricting, binge eating, purging, over-exercising, laxative use)
Current Weight
Height
Highest Adult Weight
Lowest Adult Weight
Medical History
Current Medical Conditions
Current Medications
Allergies
Any hospitalizations related to eating disorder or other medical issues?
Mental Health History
History of any other mental health concerns?
Previous or current therapy/counseling?
Current Support System
History of self-harm or suicidal ideation?
Substance Use
Do you use alcohol, tobacco, or other substances?
Family History
Family history of eating disorders?
Family history of other mental health conditions?
Family history of medical conditions?
Additional Information
What are your goals for treatment?
Other information you'd like to share