New Patient Intake Submit Info Below Step 1 of 3 33% Name* First Last Initial Email* Phone Number*Best days and time of the day to reach youDay*MondayTuesdayWednesdayThursdayFridayTime*8am-11am11am-2pm2pm-5pmAge* What type of support are you looking for?* Anorexia Nervosa Avoidant Restrictive Food Intake Disorder Binge Eating Disorder Bulimia Nervosa Disordered Eating Emotional Eating Night Eating Stress Eating Medical Conditions (Diabetes, PCOS, Renal Disease, Liver Disease, Thyroid Issues, etc - Please specify) Specific Medical Condition* Do you feel out of control when you eat?* Yes No Do you eat more rapidly than normal?* Yes No Do you eat until feeling uncomfortably full?* Yes No Do you eat large portions when not physically hungry?* Yes No Do you eat alone because of feeling embarrassed?* Yes No Do you find yourself having feelings of guilt or shame about your eating habits?* Yes No Have you been deliberately trying to limit the amount of food you eat to influence your weight or body shape?* Yes No Has thinking about food or eating made it very difficult to concentrate on things you are interested in?* Yes No Have you tried to control your weight or shape by making yourself sick (vomit) or taking laxatives?* Yes No Have you exercised in an excessive way as a means of controlling your weight?* Yes No Do you feel out of control when you eat?* Yes No Do you eat large portions when not physically hungry?* Yes No We require all new patients have EKG clearance from a cardiologist/ physician if you have not already had a recent one.PCP Name* PCP Phone*PCP Fax* 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. 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?* MM slash DD slash YYYY 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*AetnaBCBSBMCCignaHarvard PilgrimMass General BrighamTuftsUnited Health CareFallonTricareTrustmarkNational GeneralHumanaOtherSpecify Insurance Policy Name* Is your insurance*HMOPPOMASS Health InsuranceInsurance 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* HiddenTotalHiddenFull Last Name HiddenD.O.B. 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