Intake Form

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Intake Form

Thank you for contacting The Hull Institute. Please provide the information requested below. We will call you within 48 hours to get you started.

This form is confidential & HIPAA compliant.

Legal Name: *

If a minor, legal name of parent completing this form: (If not a minor, put N/A) *

Phone number (if a minor, give parent phone number): *

Email (If a minor, parent email address): *

Date of Birth: *

YYYY

Address: (City, State, Zip) *

What type of insurance do you have? *

How did you hear about us? *

Internet

Social Media

Your Doctor/Nurse Practitioner

Your Therapist

A Treatment Center

Family/Friend

Other

Your dietitian

Do you prefer? *

In person, Beachwood

In person, Rocky River

In person, Fairlawn

In person, Strongsville

Virtual

No preference

Required

Your best times for an appointment: (Our therapists sometimes have limited hours and appreciate your flexibility) *

Mornings

Afternoons

Evenings

Weekends

No preference

Required

Would you be interested in seeing a dietitian?

We highly recommend this.

Yes

What issues are you interested in working on in treatment? *

Have you been diagnosed with an eating disorder? *

Yes

If you are willing to share, what is your diagnosis?

Are you currently seeing a therapist? If so, what is their name and practice?

Anything else you would like us to know about you?

What is your preferred contact method? *

Phone

Text

No preference

Submit

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