New Patient Intake Form - Behavioral Nutrition

Is this your first-time seeking treatment?*

Yes
No

Have you attended a higher level of treatment (for example residential or partial day program or intensive outpatient program) for an eating disorder in the past?*

Yes
No

What was the most recent level of care you attended?*

Inpatient Level of Care
Intensive Outpatient Day Program
Partial Hospitalization Day Program
Residential Level of Care

When did you attend that level of care?*

What was the name of this facility?*

ARE YOU DIABECTIC?*

Yes
No

Do you have any medical conditions we should be aware of, which are not eating disorder specific?*

Yes
No

Write your Medical Conditions*

Health Insurance Policy Name*

Is your insurance*

Insurance Member ID

Do you know if your insurance is a PPO (Preferred provider options/can see someone out of network with coverage)?*

Yes
No

Are you the Primary Card Holder?*

Yes
No

Who is the primary card holder?*

How did you hear about us?*

Weight*

Height*

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Total

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Full Last Name

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D.O.B.

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Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Insurance Member ID

New Patient Intake

Step 1 of 3

You will need an EKG clearance from a cardiologist/ physician.

If you have had an EKG in the past 30 days, please have your doctor’s office fax the results to our office at 888-434-5097.

You will need recent blood work to schedule your initial assessment.

If you have had recent labs in the past 30 days, please have your doctor’s office fax the results to our office at 888-434-5097.

You will need recent blood work to schedule your initial assessment.

If you have had recent labs in the past 6 months, please have your doctor’s office fax the results to our office at 888-434-5097.