Initial Inquiry Form

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Thank you for your interest in Amrita. Please answer the following questions so we can understand your needs.

Email *

Who are you inquiring for? *

Yourself

A Loved One

A Client

Other:

Client's Legal Name *

Contact Name *

Relationship to Client *

Parent/Guardian

Self

Other:

Birth Date *

YYYY

Age *

If under 18, please list the names of Legal Guardian(s) and what is the percentage of custody.

Current Height *

Current Weight *

Preferred Pronouns

Primary Spoken Language *

Street Address *

City, State & Zip Code *

Contact Phone Number *

What times are best to contact you? *

What health insurance do you have? *

How did you hear about Amrita Eating Disorder Treatment Center? *

What type of eating disorder diagnosis or symptoms do you have? Please describe your current challenges. *

Please tell us your history with previous Eating Disorder Treatments. *

Which program are you interested in at Amrita? *

Intensive Outpatient Program: 14 hours per week including snack & dinner meal support, weekly individual therapy, family therapy and nutrition consultations

Partial Hospitalization Program: 30.5 hours per week, including lunch, snack and dinner meal support, medical monitoring of vitals and weight, medical monitoring of vitals and weight, psychiatric oversight, weekly individual & family therapy and nutritional consultation

Not sure, would like an assessment and recommendation.

Is there anything else you'd like us to know about you?

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