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This screening form is appropriate for individuals age-16 and above.
Complete this screening only if you are actively seeking treatment support.
Following submission of your screening, Michele will review it then connect with you to arrange
a consultation or intake.
It is typical for this to take 2-3 days.
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Name
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First
Last
Please provide current email
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Phone Number
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Kindly provide your current: Age/ Height/ Weight
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Part A: Eating Disorder Screening
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1. Do you experience intense fear of gaining weight?
2. Do you experience a preoccupation or distress around the appearance of your body, shape or weight?
3. Do you feel that your Self-worth is based on your weight, shape, or appearance?
4. Do you use laxatives, diuretics, enemas, or vomiting to compensate or control calorie/fat intake?
5. Do you use fasting, meal skipping, or exercise to compensate or control calorie/fat intake?
6. Do you experience irregular periods or have you stopped menstruating?
7. Do you experience episodes of rapid eating, where you consume a much larger amount of food than others would eat in the same time period (1 - 2 hours)?
8. Do you feel distress, disgust, guilt or shame following these episodes?
9. Do you feel a lack of control and feeling that you are unable to stop during these eating episodes?
10. Do you feel numb, disconnected or loose your sense of time during these episodes?
11. Do you eat until you feel uncomfortably full but do not engage in compensatory behaviours (exercise, fasting, vomiting)?
12. Do you eat to cope with thoughts, emotions, or sensations (anger, boredom, loneliness, guilt, fatigue, stress, reward)?
13. Do you have a history of dieting?
14. Do you come from a family with a history of dieting, eating disorders, or strong rules and/or attitudes around appearance, weight, food?
Please take your time and check only those items that apply to you.
Part B: Anxiety Screening
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1. Do you feel nervous or scared about the future or loosing control?
2. Do you find it hard to relax?
3. Does your breath sit high in your chest, throat, or feel shallow?
4. Do you ever experience a racing heart, numbness, tingling, dizzy, lightheaded?
5. Do you avoid people, places, or things to prevent these experiences?
Please take your time and check only those items that apply to you.
Part C: Depression Screening
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1. Do you take little interest or pleasure in things you usually enjoy?
2. Do you find yourself feeling down, hopeless, tired, or depressed?
3. Do you find it more difficult to fall asleep, stay asleep, or sleep too much?
4. Have you noticed a change in your appetite?
5. Do you experience thoughts or images of harming or injuring yourself?
Please take your time and check only those items that apply to you.
Part D: Trauma Screening
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1. Do you find it hard to trust or get close to people?
2. Do you make attempts to avoid feelings rejected or abandoned?
3. Do you question your identity, feel empty or unreal?
4. Do you find yourself feeling worthless, like a burden, disconnected, depressed, and withdrawn from people and life?
5. Do you make impulsive decisions, experience extreme shifts in mood and emotions, use alcohol, substance to cope with difficult feelings?
Please take your time and check only those items that apply to you.
Briefly, what are your hopes or desires in completing this screening?
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