New Client Intake

The information you provide here greatly helps Dina prepare for your work together.  Please take your time in carefully answering these questions as comfortable for you. All information is confidential.

Name *
Name
Address *
Address
Phone
Phone
Best number to reach you for phone appointments
If you have not been diagnosed with an eating disorder, but you have experienced purging, bingeing, or restricted eating behaviors, please comment here for our discussion.
Do you like to cook?
Have you ever been diagnosed with any of the following medical conditions, or do you currently have any of the following medical conditions?
If you have had blood work in the past 6 months, please send Dina a copy (or screenshots) of the results via email.