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Recovery Coaching Intake Form A
Email address *
Phone number *
Your answer
Residential address *
Your answer
Current age *
Your answer
What age were you diagnosed with T1D? *
Your answer
Do you use a CGM? *
Have you ever been hospitalized for DKA? *
If you answered yes to the question above please share how many times you have been hospitalized for DKA as well as the date of your most recent hospital admission *
Your answer
How long have you been struggling with your disordered eating behaviors? *
Your answer
Please specify the symptoms you struggle with. Examples include: bingeing and insulin omission, bingeing/purging and insulin omission, calorie restriction, bingeing and purging through excessive exercise, carb avoidance, avoiding testing bgs etc *
Your answer
How often you are engaging in symptom use? *
Does your endocrinologist know about your struggles with ED-DMT1? *
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 any other medical conditions? Please share below: *
Your answer
On a scale of 1-5 how committed are you to FULLY recovering from your eating disorder?
A copy of your responses will be emailed to the address you provided.
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