Self-Assessment

Email Address*

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Country*

Phone Number*

Current Age*

When were you diagnosed with T1D? *

How long have you been struggling with body image and/or disordered eating? *

Do you use a CGM? If so what brand? *

Do you use an insulin pump? If so, what brand? *

Who do you live with? If you live with other people, are they aware of your struggles, or have you been keeping it a secret?*

Do you have health insurance? If so, please let us know who your insurance provider is, and if the policy is under your name or someone else*

If we think you're a good candidate for receiving help at a treatment center, would you be willing to go? Please feel free to share any concerns you may have (if any) about inpatient or residential treatment.*

Are you currently working with a therapist? If the answer is "no," are you willing to start working with one if we help you find someone ?*

Have you tried to seek help in the past for your eating disorder? If so, please share your past experiences (therapy, treatment programs etc):*

Please share any other information about yourself that you feel is important for us to know.

On a scale of 1-5 how committed are you to recovering from your eating disorder?* On a scale of 1-5 how committed are you to recovering from your eating disorder?* 1- I know I need to deal with this, but I'm not ready to commit. 2- I WANT to recover, but I don't want to give up my ED. 3- I want to recover and I think I'm ready to try new things and make new choices in order to do that. 4- I'm ready to recover. I'm ready to embrace the fact that this is going to be really hard. 5- I'm ready to recover. No matter how challenging it is.