Eating Disorder Counseling Consent and Intake Form

Consent

I acknowledge that I am voluntarily seeking counseling services for eating disorder concerns. I understand the purpose, benefits, potential risks, and alternatives of counseling. I have had the opportunity to ask questions and my questions have been answered to my satisfaction. I consent to participate in counseling sessions.

I agree to the above statement.

Personal Information

Full Name Date of Birth Age Email Address Phone Number Address

Emergency Contact

Name Relationship Phone Number

Medical and Mental Health History

Primary Care Physician Current Medications Past or Current Medical Conditions Past or Current Mental Health Diagnoses

Eating Disorder Overview

Describe your concerns regarding eating, body image, or related behaviors How long have you experienced these concerns? Have you previously received treatment for an eating disorder? If yes, please specify type and dates of treatment

Additional Information

What are your goals for counseling? Is there anything else you would like your counselor to know?

Signature

Client Signature Date