Referral Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Referral Form

BodyKind Vail accepts self, family, and professional referrals to connect individuals with peer support, recovery resources, educational programs, and community-based eating disorder support services.

Your First and Last Name *

Your Email *

Individuals' First and Last Name *

Individuals' Date of Birth (if known)

YYYY

Individuals' Contact Information (phone and/or email) *

Individuals Preferred Contact Method *

Individuals Preferred Language *

Individuals Pronouns *

Behavior Concerns *

Restrictive eating behaviors

Binge eating behaviors

Compensatory behaviors (e.g., vomiting, misuse of laxatives/diuretics, over exercising)

Sudden significant weight change (loss or gain)

Preoccupation with food, body image, or weight

Avoidance of eating with others or in social settings

Emotional distress related to food or body image

Loss of interest in hobbies

Noticeable impact on school, work, relationships

Dental or medical concerns possibly related to disordered eating

Rigid food rules (counting calories, only eating at certain times, all-or-nothing rules, food-group restrictions)

Showing secrecy with eating (e.g., hiding food in room, hiding food wrappers, lying about food)

My individual is in recovery

Required

Type of Support Requested *

Peer Support Groups

One-on-One Peer Support / Mentoring

Meal Support Program

Workshops

Help Connecting to Clinical Care

Other

Required

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

Clear form

Never submit passwords through Google Forms.

Forms

This content is neither created nor endorsed by Google.