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Client Self-Assessment Form
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!
Email address *
What is your first name? *
Your answer
What is your last name? *
Your answer
What is your email address? *
Your answer
Where do you live? Please include state, city and zip code. *
Your answer
How old are you?
Your answer
When were you diagnosed with T1D? *
Your answer
Are you struggling with an eating disorder? *
If you answered yes to the previous question, how long have you been struggling with body image and/or disordered eating?
Your answer
If you are not struggling with eating disordered behaviors, please share the main concern that you're seeking support for.
Your answer
Do you use a CGM and/or an insulin pump? *
Your answer
Who do you live with? If you live with other people, are these people aware of your struggles or have you been keeping it a secret?
Your answer
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. *
Your answer
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.
Your answer
Please share any other infomation about yourself that you feel is important for us to know.
Your answer
On a scale of 1-5 how committed are you to recovering from your eating disorder?
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