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Assessment Form for Parents, Spouses, Family and Friends
This form is required for individuals who are seeking help from our staff for a loved one. Please answer as honestly and thoroughly as you can; the more information we have, the easier it will be for us to help you!
What is your last name? *
Your answer
What is your first name? *
Your answer
What is your email address? *
Your answer
Where do you live? *
Your answer
What is the name of the person you are seeking services for?
Your answer
How old is he or she?
Your answer
Where does he or she live (city, state, and zip code)? *
Your answer
What is your relationship with this individual?
Are you their parent, spouse, sibling or friend?
Your answer
Is your loved one struggling with an eating disorder? If so, how long have they been struggling with body image and/or disordered eating?
Your answer
If your loved one is not struggling with eating disordered behaviors, please share with us what your main concern is that you are seeking support for.
Your answer
Please share any other infomation you feel is important for us to know about the individual you are concerned about.
Your answer
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