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You may complete this form online by answering the following questions to the best of your ability. Once completed, please copy your completed form, click on the e-mail address below and paste your completed application in the body of the e-mail and send. Please note that all the information you provide is kept confidential. If you would rather fax the application, please print a copy of this form, complete it and fax it to 810-714-1025. Please let us know if you are currently working with a facilitator of an EDEN program.
Contact Information
Name:
Address:
City: State: Zip:
Phone: Best Time to Call :
May we contact you at this phone number?
Email : Birthday:
General Information
How did you hear about EDEN?What attracted you to EDEN?
What do you hope to accomplish by participating in EDEN?
Is anyone aware of your unhealthy behaviors?
If yes, who?
How long have you been struggling?
Where do you feel you are at this point with unhealthy behavior?
Have you taken any steps to change your unhealthy behaviors?
f yes, which of the following have you tried?
If other (please explain):
Do you feel that you have the potential to change your unhealthy behaviors?
Have you received, or are you currently receiving, any
treatment for anorexia or bulimia or compulsive/emotional eating?
If yes, indicate the approximate dates, length, types and locations of treatment
received:
Do you currently exercise?
If yes, how many time per week? How long per session?
Please describe in detail your exercise program?
Please describe in detail your current eating behaviors?
Since EDEN is a positive atmosphere, please write something you see as positive about yourself.
Have you particpated in an EDEN program before? If yes, who was your facilitator?