Intake Questionnaire Hi! We’re so glad you’re here. Get started in just three easy steps: Fill out our online intake form We’ll get back to you within 24 to 48 business hours We’ll match you with the best clinician for your needs Chosen or Preferred Name * First Name Last Name Legal Name if different from above First Name Last Name Caregiver name - if reaching out on behalf of someone else First Name Last Name My pronouns are: Email * Date of Birth * MM DD YYYY How would you like to meet? Telehealth In-person It doesn't matter Not sure - let's chat Which services are you interested in? Not sure - let's chat! Nutrition Counseling Mental health therapy Binge Eating Eating disorders Anorexia Nervosa I want to quit dieting Multicultural counseling Anxiety Therapy Dance Movement Therapy Couples & Family Therapy Body Image Intuitive Eating Bulimia Other Do you have a preferred clinician? Not sure - let's chat! Doesn't matter Alison Boeke, RDN, LMHC Amy Rastogi, LMHCA Chloe Omlid, CN Cynthia Pytel, RDN Maura Reagan, LMHC, R-DMT Sarah Douglas, CN, LMHCA Rosanna Sze, LSWAIC Do you have a preference for a BIPOC and/or non-white clinician? Doesn't matter Not sure Yes No Who is your insurance provider? * Private pay or out-of-network Premera Blue Cross Lifewise Regence Blue Shield Kaiser Health Plan of WA First Choice Health Network Anthem Blue Cross Blue Shield Asuris Healthcare Management Administrators Not listed here How did you hear about us? * Google search My dietitian or nutritionist My therapist My primary care provider Friend or family member Opal Food + Body Wisdom Center for Discovery Eating Recovery Center The Emily Program One Connection Healthcare Thira Health Other Sunrise Nutrition uses a Health at Every Size and Anti-oppression approach to nutrition and mental health. We believe a person's worth is not judged by the size and shape of their body. Subsequently, an individual's health is not measured by their weight or clothing size. Instead, we choose to focus on having a positive relationship with food, finding joyful movement, living authentically, and addressing overall quality of life. * Please check all to proceed I understand that in filling out this online intake form, I am looking to establish services at Sunrise Nutrition I understand that my care at Sunrise Nutrition will not include the prescription of restrictive diets, dieting behavior or weight loss services. I understand that my clinician will assess for fit during intake and may recommend other outside treatment options instead of Sunrise Nutrition, if necessary. In addition to offering nutrition counseling, our Nutrition Team also works in tandem with primary care providers in monitoring medical stability. I understand that if necessary, my dietitian or nutritionist may require me to establish care with an eating disorder-informed PCP. Some people have privileges and benefit from them. * True False It's complicated I'm not sure Other People are treated differently according to their body size. * True False It's complicated I'm not sure Other Share your knowledge of Health at Every Size. * Please check all that apply I’m familiar with it, and I disagree with it. I’m familiar with it; disagree with it, but am open to changing my mind. I’m familiar with it, but not sure how to feel about it. I’m interested in learning more. I’m familiar with it and agree with it. That’s why I’m here! I know the basics, but not much beyond that. I’ve never heard of it, but I'm interested in learning more. I’ve never heard of it and I’m not interested in learning about it Health at Every What? Other I am open to exploring themes centered around racism, fatphobia and oppressive systems as it relates to my experience with food and body image. * Yes - I’m always down for these conversations Yes - if it’s relevant to my treatment It’s not really my thing, but I’m open It doesn't really matter to me No - it’s not my thing and I don’t want to talk about it. It’s complicated I’m not sure Other Please check all statements that you agree with, either partially or wholly: * I am super motivated to get going every single day!!!!!!!!!! I'm motivated to get started on treatment. I'm motivated on most days. I'm motivated some days, depending on my mood. I'm motivated 1-2 days out of the week. I'm not motivated to start treatment. I’m here only because another member of my care team says I need to be, but I’ll do what I am “supposed to.” I’m here only because another member of my care team says I need to be. I will not be participating in future sessions. It's complicated Meh Other Sunrise Nutrition’s clinical team is made up of a diverse group of people with varying identities and life experiences. We have several team members that belong to marginalized groups, which is valuable to the treatment experience. We truly do our best work when the clinician and the client are a good fit for one another. * Please check all to proceed I understand that if at any time, my clinician feels another team member might be a better fit for me, they may refer me to another team member or make an outside referral. I understand that if at any time, my clinician experiences harm, they may refer me to another team member or make an outside referral. Please check all that apply: I am not seeking care for an eating disorder or related concerns I have an undiagnosed eating disorder I have an eating disorder that has been diagnosed by a mental health professional I don't care much for "diagnoses." I just know something's wrong. I’m worried about my relationship with food, but I don’t have an eating disorder I want to stop dieting I have thoughts of dissatisfaction about my body I want to stop overeating and/or bingeing I’ve had issues with food and body image my whole life My concerns with food and body image are relatively new This is my first time seeking care for my relationship with food and/or body image I’ve seen a therapist before I’ve seen a nutritionist or dietitian before I’ve sought treatment for an eating disorder before None of the above apply Please share anything that would be helpful for us to know Thank you!
