True Image Care
All answers are kept strictly confidential and for the purposes of fitting you with the best group possible.
Full Name
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First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
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Mayotte
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Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Turkish Republic of Northern Cyprus
Northern Mariana
Norway
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eSwatini
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Switzerland
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Timor-Leste
Togo
Tokelau
Tonga
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Uruguay
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Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Home Phone
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Area Code
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Area Code
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Personal Information
Birth Date
*
Please select a month
January
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Month
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Day
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1920
Year
Relationship Status
*
Please Select
Single
Married
Divorced
In a Committed Relationship
Do you have children?
*
Please Select
YES
NO
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Emergency Contact
Full Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone Number:
*
-
Area Code
Phone Number
E-mail:
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Church
Do you attend Discovery Church?
Please Select
YES
NO
Which campus do you usually attend?
Please Select
YES
NO
Do you attend a local church?
Please Select
YES
NO
What is the name of the church you attend?
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Past Experience
How long have you had your eating disorder?
Have you had any previous treatment for your eating disorder? (inpatient, day treatment, IOP, outpatient therapist, dietitian, other)
Are you currently receiving treatment for your eating disorder?
Please Select
YES
NO
How long have you received treatment?
What type of professionals are you working with? (therapist, dietitian, medical, other)
Does your family and/or loved ones know about your eating disorder?
Please Select
YES
NO
Besides your family and/or loved ones have you ever told anyone of your eating disorder?
Please Select
YES
NO
Do you binge? Meaning, do you eat a larger than normal amount of food in a rapid amount of time?
Please Select
YES
NO
When you binge, do you feel out of control/guilt/shame when doing so?
Please Select
YES
NO
Do you feel in a trance when bingeing?
Please Select
YES
NO
How often do you binge?
Please Select
Once a day
Multiple times a day
Weekly, but not daily
Do you skip meals?
Please Select
YES
NO
Do you fast regularly?
Please Select
YES
NO
Do you regularly avoid entire food groups (carbohydrates, meat, dairy), count calories, count fat grams in attempt to lose weight, prevent weight gain?
Please Select
YES
NO
On a scale of 1-10, how dissatisfied are you with your body? 1 being “I am completely satisfied and appreciate my body.” 10 being “I hate my body, it plagues me”:
1
2
3
4
5
6
7
8
9
10
Completely satisfied with my body
I hate my body
1 is Completely satisfied with my body, 10 is I hate my body
Do you throw up what you eat to get rid of calories?
Please Select
YES
NO
How often do you throw up?
Please Select
Multiple times a day
Daily
Weekly, but not daily
Do you use laxitives?
Please Select
YES
NO
How often do you use laxitives?
Please Select
Multiple times a day
Daily
Weekly, but not daily
Do you use diet pills, diuretics, ipecac?
Please Select
YES
NO
What kind of pills do you use?
How many pills?
How often do you use pills?
Please Select
Multiple times a day
Daily
Weekly, but not daily
Do you exercise?
Please Select
YES
NO
What is your average duration of exercise? (minutes)
How many days a week do you exercise?
Do you cut up your food into small pieces, eat food in a certain order, eat really slow, use excess amounts of condiments, have lots of special requests at restaurants?
Please Select
YES
NO
Has your physician, family, loved ones, treatment team told you that you are underweight?
Please Select
YES
NO
Do you currently battle medical complications typically associated with an eating disorder? (Osteoporosis, low potassium, low sodium, slow heart rate, low blood pressure, anemia, reflux etc.)
Please Select
YES
NO
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