Intuitive Eating Survey Intuitive Eating Jumpstart Survey To get started, please answer the questions below Name Email Phone Number Age In a few sentences describe your reason for seeking help from a dietitian nutritionist? Describe what ideal success would mean as we work together Why are you not reaching your goals right now? If we decide we're a good fit, how soon can you get started? What statement BEST describes you: I am willing and able to invest time and resources to improving my health and making lasting changes in my life I am curious about improving my health but not sure if now is the right time or not I have absolutely no desire to change my diet or do anything other than what I am currently doing What health conditions have you been diagnosed with? Anorexia Nervosa Anxiety Binge Eating Disorder Bipolar Disorder Bulimia Nervosa Depression Diabetes Disordered eating / dieting (NOT a clinical eating disorder) Heart Disease High Cholesterol Kidney Disease OSFED/EDNOS Personality Disorder Self-harm Thyroid Disease Other (please describe below) No major health diagnoses Other Please select any healthcare providers you currently see: Primary Care Physician Endocrinologist Psychotherapist Psychiatrist Naturopath/Holistic Practitioner Other (please list below) Other Some portions of the program are covered by insurance and some portions are out of pocket. Is this a problem for you? Yes, I am willing to invest in my health No, I am only interested in what insurance will cover Agreement I agree that if I have a clinical eating disorder diagnosis I may be required to establish a treatment team including psychotherapist and medical doctor in order to work together. Submit my survey!