Clinical assessment application

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Prior to starting this application, please review the Guidelines. Those completing the form for another individual, please do so as it applies to the person who is in need of the assessment.

This application will become part of the assessment file with approval into the program. Completion of this form indicates that you have reviewed and accept the guidelines.

Email *

Last name applicant *

First name applicant *

Pronouns *

She/Her

He/Him

They/Them

Prefer not to say

Other:

Date of birth *

YYYY

Phone number *

Mailing address (street) *

Mailing address (city) *

Mailing address (state) *

Mailing address (zip) *

Mailing address (county of residence) *

With whom do you reside? *

Please select the option below that best reflects your gender identity *

Cisgender female

Transgender female

Cisgender male

Transgender male

Gender nonconforming

Nonbinary

Questioning

Prefer not to say

Other:

Please select the option below that best reflects your current relationship status *

Single

Married

Separated

Divorced

Widowed

Domestic partner

Prefer not to say

Other:

Please select the option below that best reflects your racial identity *

Native, Indigenous, or First Nations

Arab or Middle Eastern

East, Southeast, or South Asian

Black or African American

Caucasian or White

Pacific Islander

Latine, Laine, Latina/Latino, or Hispanic

Prefer not to say

Unsure

Other:

Are you (or have you been) in the care of a clinician (therapist and/or dietitian) for disordered eating and/or eating disorders concerns? *

Yes

Other:

Do you identify as disabled or neurodivergent? If so, please briefly explain. *

Do you have any religious affiliation/s? If so, does your religious affiliation potential impact your treatment options? *

Do you have insurance? If so, please identify the provider *

What is your household income range *

$0-50,000/year

$50,000-75,000/year

$75,000-100,000/year

Over $100,000/year

Other:

If you are completing this form on someone else's behalf (you are the parent/guardian of a minor, parent/guardian of an adult dependent applicant, or a provider who has permission to submit the form on the individual's behalf) - please identify the relationship

If you are completing this form on someone else's behalf, please provide your first and last name

If you are completing this form on someone else's behalf, please provide your telephone number

Please use this space to include any other information you feel is pertinent as we consider your application

Send me a copy of my responses.

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