Eating Disorder Program Application

First name

Last name

Email address

Phone number

Date of Birth

At the time we only accept ages 18+ for this program

How did you hear about us / Who referred you?

Are you stepping down from an inpatient or residential program? If so, where?

What type of eating disorder concerns are you seeking treatment for?

Insurance Company

Subscriber ID

Group Number

List current medications

Current/ past diagnosis

Questions/ Concerns?

Someone will reach out for admission paperwork and to schedule an intake appointment should you qualify for the program. Thank you.

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