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Confidential Assessment

Please fill out this short form to receive a confidential assessment:

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Eating Disorder Confidential Assessment Form
First Name: *
Last Name:
Email address: *
State: *
Phone:
Inquiring About:
Age of Individual:
Individual's First Name:
Individual's Last Name:
Individual's City:
Individual's State: *
Briefly describe the eating disorder history of the Individual:
 
What problems has the eating disorder caused the family?
 
What kind of help do you think the Individual needs?
 
Current Medications:
Any prior treatment? If so, where and what level(s) of care?
 
Any mental health diagnosis (ED, drug addiction, or otherwise)?
If yes, when was the diagnosis made?
 
Do you ever eat in secret?
 
Do you eat when you are upset?
 
Can you tell when you are full?
 
How did you hear about New Dawn Recovery Centers?
 
Other Comments:
 
Preferred method(s) of payment (select one or more):
  Private insurance
Self-pay
Need financing
Self Assessment
For each question, please mark one answer that best describes you.
1. Am terrified about being overweight.

Always
Usually
Often
Sometimes
Rarely
Never
2. Avoid eating when I am hungry.

Always
Usually
Often
Sometimes
Rarely
Never
3. Find myself preoccupied with food.

Always
Usually
Often
Sometimes
Rarely
Never
4. Have gone on eating binges where I feel that I may not be able to stop.

Always
Usually
Often
Sometimes
Rarely
Never
5. Cut my food into small pieces.

Always
Usually
Often
Sometimes
Rarely
Never
6. Aware of the calorie content of foods that I eat.

Always
Usually
Often
Sometimes
Rarely
Never
7. Particularly avoid foods with high carbohydrate content (e.g. bread, potatoes, rice, etc.).

Always
Usually
Often
Sometimes
Rarely
Never
8. Feel that others would prefer if I ate more.

Always
Usually
Often
Sometimes
Rarely
Never
9. Vomit after I have eaten.

Always
Usually
Often
Sometimes
Rarely
Never
10. Feel extremely guilty after eating.

Always
Usually
Often
Sometimes
Rarely
Never
11. Am preoccupied with a desire to be thinner.

Always
Usually
Often
Sometimes
Rarely
Never
12. Am preoccupied with the thought of having fat on my body.

Always
Usually
Often
Sometimes
Rarely
Never
13. Take longer than others to eat my meals.

Always
Usually
Often
Sometimes
Rarely
Never
14. Avoid foods with sugar in them.

Always
Usually
Often
Sometimes
Rarely
Never
15. Feel that food controls my life.

Always
Usually
Often
Sometimes
Rarely
Never
16. Display self control around food.

Always
Usually
Often
Sometimes
Rarely
Never
17. Feel that others pressure me to eat.

Always
Usually
Often
Sometimes
Rarely
Never
18. Give too much time and thought to food.

Always
Usually
Often
Sometimes
Rarely
Never
19. Feel uncomfortable after eating sweets.

Always
Usually
Often
Sometimes
Rarely
Never
20. Engage in dieting behavior.

Always
Usually
Often
Sometimes
Rarely
Never
21. Like my stomach to be empty.

Always
Usually
Often
Sometimes
Rarely
Never
22. Have the impulse to vomit after meals.

Always
Usually
Often
Sometimes
Rarely
Never