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recovery@givawilkerson.com
yoga@givawilkerson.com
267-314-7893
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First name
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Last name
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Email
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Date of Birth
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Month
Month
Day
Year
Occupation
Pronouns
Race/Ethnicity
How long have you been struggling with disordered eating?
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Please describe your eating disorder and/or eating disorder behaviors.
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Have you been formally diagnosed with an eating disorder?
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Yes
No
If yes, please provide your diagnosis and the year of your diagnosis below.
Have you been diagnosed with any other mental health disorders or conditions?
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Yes
No
If yes, please list the disorders/conditions below.
Have you ever sought treatment for your eating disorder?
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Yes
No
If yes, please list the types of treatment and the years you received treatment (this includes support groups and hospitalizations).
Did you find your past eating disorder treatment helpful? Please explain why or why not.
Are you currently in the care of a licensed therapist?
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Yes
No
If yes, please provide your therapist's name and contact information (email and phone number)
If you are not in the care of a licensed therapist, are you interested in being connected to one?
Are you currently in the care of a registered dietitian (RDN)?
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Yes
No
If yes, please provide your dietitian's name and contact information (email and phone number)
If you are not in the care of a registered dietitian, are you interested in being connected to one?
Are you currently pregnant?
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Yes
No
If you are currently pregnant, how many weeks are you?
Please list any additional medical or mental health conditions you are currently living with.
Please provide the names, titles and contact information (email and phone number) for your additional medical and mental health providers.
Briefly explain why you are seeking a coach at this time.
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What is your motivation for recovery (What are you recovering to?)?
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