Name: ______________________________________________________________ 

Education Level:  _____________________________________________________

Date of Birth:  _______________________________________________________

Marital Status: _______________________________________________________

Occupation: _________________________________________________________

Children (Name and ages):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

When did you first notice your child was having difficulties with an eating disorder?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Please describe the eating-disordered behaviors you have witnessed and/or suspected with your child.
Please differentiate between what you have actually seen from what you suspect or have heard from others.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have you spoken with your child regarding your concern? If so, how has your child reacted? If you have not
spoken, why?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Have others approached you with concerns for your child? If “Yes’” please list those people, an state their
concerns (as stated to you):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

What impact, if any, has your child’s eating disorder had on your family system?   Have you noticed changes
within the family system either prior to, or since, the development of your child’s eating issues?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

In your opinion, what do you believe your child has developed an eating disorder? (Please check all those
that apply):

• ________ teasing about appearance
• ________ problems at school/work
• ________ media influences
• ________ conflicts between you and your spouse
• ________ conflicts between siblings
• ________ conflicts between you/your spouse, and your child
• ________ puberty and assoc. changes
• ________ medical reasons (illness/operation)
• ________ depression
• ________ loss/divorce
• ________ difficulty coping with stresses(s)
• ________ obsessive/compulsive tendencies
• ________ relational issues with friends
• ________ leaving home/separation
• ________ issues with sexuality
• ________ difficult sexual experience
• ________ family difficulties
• ________ prolonged period of dieting
• ________ recommendation of weight loss by parent, physician, coach, other
• ________ other reason (please state):
  ___________________________________________________________________________________
  ___________________________________________________________________________________
  

Please describe the relationship you have with your child:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Please describe the relationship your child has with your spouse/partner:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Please describe the relationship your child has with his/her siblings:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Whose initiative was it to seek out treatment for your child?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

How willing are you to become involved in your child’s treatment (including family therapy):

• ________ very willing
• ________ somewhat willing
• ________ not at all willing

Please describe your child’s developmental milestones, as well as strengths and weaknesses (socially,
academically, physically, emotionally):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Were there other stresses, losses, or difficult experiences that coincided with your child’s development of an
eating disorder?   (Y/N) ________  If yes, please describe:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

FAMILY HISTORY:

Please note family members that have experienced the following:

Please list any questions you would like addressed concerning your child and treatment planning
(as well as questions you have regarding eating disorders):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

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