Confidential Eating Disorder Intake Assessment

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Patient Information
Marital Status
Gender Identity
Sexual Orientation
Religious Preference
Insurance Information

Primary Insurance

the one providers should call

Secondary Insurance

the one providers should call
Guarantor (Financially Responsible Party) Information
General Information
How did you hear about Carolina House?
Are you currently employed / in school?
Are you having difficulties at work / school?
If yes, will require filling out an extra form, and we will need a copy of the court order prior to admission.
If you are an adolescent, are your parents divorced? (If yes, we will need a copy of the custody agreement.)
Health Information
in pounds
in pounds
in pounds

Allergies

Please list all of your food and non-food allergies. Medical documentation for food allergies is required.

e.g., dogs / itchy eyes, sneezing
Do you have medical documentation for these allergies?
Please note: Some medications may be altered or withdrawn after your meeting with our medical team.
Eating Disorder History

For the following section, please indicate your behaviors for the last 30 days. If you are currently in treatment, please answer regarding your behaviors before entering treatment.

On average, how many days per week do you restrict your food?
What purging methods do you use?
On average, how many times a week do you binge?
On average, how many days per week do you exercise (for any length of time, including any sports practiced or consistent body movement that you might do for your employment)?
Do you exercise at night?
Why do you exercise?
e.g., 24-hour recall, chew/spit behavior, intestinal bypass, caffeine use, chewing gum or ice, substance abuse
Substance Abuse History

Fill out below where applicable.

Marijuana Use

Cocaine/Crack Use

Methamphetamine Use

Amphetamine Use

(e.g., Adderall)

Barbiturate Use

(e.g., Amytal, Nembutal, Seconal)

Heroin Use

PCP Use

Hallucinogen Use

Benzodiazepene Use

(e.g., Valium, Ativan, Xanax)

Inhalant Use

Alcohol Use

Type of Alcohol Used

Opiate Use

Synthetics Use

(e.g., Bath Salts, Ecstasy/MDMA)

OTC Medication Use

(e.g., Cold/Cough Medication)

Nicotine Use

Mental Health History
Have you ever been diagnosed with any of the following?
Are you currently having suicidal thoughts?
Are you currently engaging in self-harming behaviors (e.g., burning, cutting, hitting)?
Treatment Information
Are you currently in treatment?
If so, are you engaging in disordered behaviors in treatment?
On a scale of 1-10, how motivated are you to receive treatment (10 being extremely motivated)?
On a scale of 1-10, how much do you fear gaining weight (10 being extremely afraid)?
Are you able to commit to being safe while at Carolina House?
Do you have an outpatient psychiatrist?
If admitting into IOP you will need your own outpatient psychiatrist.

From my first call inquiring about getting help I found the staff at Carolina House to be super helpful, informative, and understanding.

– a former resident
Our Treatment Modalities