1. What is your name?

2. How old are you?

3. Where do you live?

4. What type of eating disorder do you have?

5. How long have you struggled with this eating disorder?

6. Have you been in treatment before? If yes, how many times, for how long, and where?

7. What is your height/ weight?

8. What is your typical daily calorie intake?

9. Do you purge? If yes, how often?

10. Describe your exercise level.

11. What is your yearly family income?

12. Why do you want to get better?

13. Do you suffer from any other mental or physical illnesses?

14. What, if any, obstacles do you forsee after treatment?

15. What makes you a good candidate?

16. Describe your support team. Include both professional and family and friends.

17. What makes this time different?