Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
What is your date of birth, including year?
*
If you are filling this out for someone else, let us know and provide their birth date.
Would you like to share any notes about your medical stability?
If you do have medical issues because of an ED, but want out-patient support, please indicate that here.
Your availability
*
Check the days and times you are available. This will help us to match you with your dream team, and make sure you get what you need.
Can we text you with scheduling questions?
Add any notes about your availability or preferences here:
Check any symptoms that you are experiencing.
*
Let us know what symptoms you are experiencing related to food, your body, and exercise
Check any other concerns you have.
*
Let us know what symptoms or concerns you have unrelated to eating, body image, or exercise.
What else do you want us to know?
Say as much or as little as you'd like about you, your history, your goals, or your current struggles. If you want to work with a particular clinician, let us know here.
Acknowledgement
*
Please don't ghost us!
Thank you! You can expect to hear back from us within 24 business hours. You can expect to be paired with the best clinician(s) for you, get a fist session(s) scheduled, and receive guidance in next steps (documents in your client portal). Email Veronica@ACEDatx.com with any questions.
