Intake form

Help us serve you better

Name *

Email address *

What is your relationship to the child with an eating disorder?

What is the child's age?

Has the child received a formal diagnosis?

If yes, please specify the diagnosis.

What treatment options have been explored?

Please select at least one option.

Therapy

Medication

Nutritional Counseling

Hospitalization

None

What are your primary concerns regarding your child's eating disorder?

What is your profession?

What is your highest level of education?

Are you currently working with any healthcare providers regarding your child's condition?

If yes, please list their specialties or roles.

What specific support are you seeking from Nature&Nurture?

Additional questions or comments

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