Body Image for Active Girls

Thank you for your interest this program! Please complete this form so we can learn more about your child. We will review the information and reach out about next steps.

Please note that information collected on this form will be kept confidential and will not be shared with others outside of our practice.

Child's first name

Child's last name

Child's date of birth

Parent/guardian last name

Email address

Phone number

Please tell us about your child and why you are interested in this program.

Has your child been diagnosed with an eating disorder (e.g., anorexia, bulimia, ARFID, orthorexia, etc.), or do you suspect your child has an eating disorder?

Please feel free to share any important information about your child's health, development, and any diagnoses (e.g., ADHD, Anxiety, Mood Disorder, Autism).

Do you have any questions about this service?

Your information will be encrypted.

Body Image for Active Girls

Thank you for your interest this program! Please complete this form so we can learn more about your child. We will review the information and reach out about next steps.

Thank you for your interest this program! Please complete this form so we can learn more about your child. We will review the information and reach out about next steps.

Riverwise Psychological Services