EATSANE Admission Application

(Part B)

     
Client ID# :

  
1. Are you currently employed or going to school?


 
Work Schedule:

  
School Schedule:

 
Check One:
 
2. Do you have a previous or current mental health problem?

 
If yes, any current medications being taken? List:  
3. How long have you abstained from overeating?  
4. Do you have withdrawal problems when you refrain from overeating?


 
If Yes, please explain symptoms:



 
5. With whom are you currently living?

 
List number of household members actively overeating:

  
6. Marital Status

   
  Married (or significant other):

 
Spouse (or Partner) Name:

 
7. Presenting Problem --Why are you seeking continuing care?

 
7a. Number of Prior Treatment Experiences for Compulsive Overeating
(for compulsive overeaters ONLY): 		 
Previous Eating Disorder Treatment:
Program Name Type of Treatment Dates of Treatment Completed Treatment Length of Abstinence:
  
8. Attendance in Twelve-Step Meetings?
 
9. History of Relapse:    
Longest Period of weight stabilization (from when to when):  
Triggers: (check all that apply):
 
 
 
Briefly describe last relapse:  
Other Triggers: Describe  
Characteristics:  
Usually eat with whom?
 
Particular days of the week when you are most vulnerable:
 
Particular Events (Please List):
  
Never overeat on (please list days/times):  
     
10. Any trauma in childhood?    
If yes describe:  
11. Describe adolescent years (drug use, relationships among peers, intimacy, school performance):
  
12. Describe events that led up to being referred to EATSANE:  
     
13. OTHER COMPULSIVE BEHAVIORS
   
Gambling Activity:  
Drug and or Alcohol:  
Other:  
14. Current Employment:    
Job title/duties:  
Company name:  
Employment Status F/t (36+ hrs. per week) or P/T ( < 35 hours per week):
 
Job hours/days:  
Job Satisfaction (0-10):  
Is job in jeopardy?
 
     
   
     
     
For Office Use Only:    
     
Date of Review:

  
Reviewer:

  
Admission Date: