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This form is required for individuals who are seeking help from our staff. Please answer as honestly and thoroughly as you can; the more information we have, the easier it will be for us to help you!
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Email *
First name *
Last name *
Address line 1 *
Address line 2 *
City *
State *
Zip/postal code *
Country *
Best phone number to reach you: *
Current age *
When were you diagnosed with T1D? *
How long have you been struggling with body image and/or disordered eating? *
Do you use a CGM? If so what brand? *
Do you use an insulin pump? If so, what brand? *
Who do you live with? If you live with other people, are they aware of your struggles, or have you been keeping it a secret? *
Do you have health insurance? If so, please let us know who your insurance provider is, and if the policy is under your name, a spouses name or other family member. *
If we think you're a good candidate for receiving help at a treatment center, would you be willing to go? Please feel free to share any concerns you may have (if any) about inpatient or residential treatment. *
Are you currently working with a therapist? If the answer is "no," are you willing to start working with one if we help you find someone who is empathic and non-judgemental? *
Have you tried to seek help in the past for your eating disorder? If so, please share your past experiences (therapy, treatment programs etc): *
Please share any other information about yourself that you feel is important for us to know.
On a scale of 1-5 how committed are you to recovering from your eating disorder? *
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