Referral Form

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Referral Form

This referral form serves as a bridge to support your loved one who has been affected by an eating disorder or disordered eating behaviors, in a safe, respectful, and caring manner. By collecting basic information, observed concerns, and personal goals, it allows us to provide a connection to appropriate programs, peer-based support, and, if needed, connections to higher levels of care.

Your First and Last Name *

Your Email *

Individuals First and Last Name *

Individuals Date of Birth *

YYYY

Individuals Contact Information *

Individuals Preferred Contact Method *

Individuals Preferred Language *

Individuals Gender Identity *

Individuals Pronouns *

Individuals Race *

Individuals City of Residence *

Individuals Parent/Guardian (if minor)

If the individual is under 12, may we contact the parent/guardian?

Yes

Unknown

Clear selection

Health Insurance? *

Yes

Unknown

If Yes, What Health Insurance? (e.g., Cigna, Medicaid, United Healthcare, etc.)

Behavior Concerns *

Type of Support Requested *

If this is a referral for clinical care, what specific services are being requested?

What goals or outcomes does the individual hope to achieve through support? (Optional)

Is there any additional information that would help us best support the individual? (Optional)

Submit

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