30 Minute Assessment Questionnaire — Eating Disorder Treatment Get Help By Calling Our Scottsdale Eating Disorder Treatment Center – (480) 214-9543 The free 30-minute assessment we provide offers a way for us to meet one another and offers you the experience of our therapeutic approach and treatment center. The assessment will also provide you with a greater educational understanding of Eating Disorder Treatment and how The Gateway Institute can help you personally. The assessment is completely free and confidential. Type of Eating Disorder and Other Related Concerns- Check all that apply Bulimia (BN) Anorexia (AN) Binge Eating Disorder (BED) Avoidant/Restrictive Food Intake Disorder (ARFID) Other specified feeding or eating disorder (OSFED) Exercise Compulsions Body Image Concerns Orthorexia Please check all that apply Guilt if don't exercise and/or exercise when tired, fatigued, sick or injured Preoccupied with clean or healthy eating Preoccupied with weight, food, calories, fat, carbs or dieting Limit or cut out certain foods and/or skipping meals Preoccupied with body size and shape Frequent mirror checking, body checking, comparison to others Changes in school and/or work performance, social activities, mood, sleep, weight and/or energy Lack of control and/or not present when eating Feelings of guilt, shame and disgust after overeating; eating in secret and/or hoarding food Perception of one's body differs from others' perception Vomiting, diet pills, laxatives and/or supplements Fears of vomiting or choking Rigidity with meal times and/or rules around food Have you ever recieved treatment for an Eating Disorder before? Yes No Are you contacting on behalf of a loved one? Yes No Name* First Last Age5-1011-1516-1819-2424-3334-4041-5051-6061-7071-85Phone*Email* Other Info