Assessment and Treatment Tools

Overview of Disordered Eating Assessment and Treatment Tools

INTAKE FORMS 

– You can put these intake forms on your website so clients can download and complete them in advance (which is what I do), or clients can complete them in your office. 

Client Intake and Payment Authorization Form – Client fills in name, address, phone number(s) and email address; referral source, emergency contact information and payment information. In Word.

Nutrition Assessment for Eating / Weight Concerns - This four page nutrition assessment focuses on eating/weight issues and potential eating disorders. It is Word format so that you can alter it to fit your needs. In Word.

Nutrition Assessment for MNT – Similar to above assessement so that it identifies eating and weight concerns, but has an medical nutrition therapy (MNT) focus. Also 4 pages. In Word.

 Informed Consent – Used to obtain and release confidential information. In Word.

FIRST SESSION FORMS

HIPAA Privacy Notice and Policy Agreement – To inform clients about HIPAA without having to hand out the long form each time. Also outlines payment and cancellation policies. In Word.

Nutrition Assessment for RDN (1 page) – Simple assessment form that I have found useful since 1992 and use daily in my practice. Prompts for history and good/bad days with food. In Word.

COUNSELING FORMS

Consequences of Healthy-Restrained Eating and Restricting Food Intake – Checklist for client. Points out consequences of food restriction. The fact that it is from the Keys Study and the subjects were male is hidden. Finding out what these men experienced is always an eye opener for clients.

The Hunger Scale- Visual guideline to help client reconnect with hunger, fullness and satisfaction using a 0-10 scale with descriptions of each number. This provides you and your client a “language” with which to discuss their eating experiences.

My Hunger Scale – A blank Hunger Scale for clients to fill in, exploring their experience of hunger and satiety. A great tool to make sure you and the client are on the same page when discussing each of the levels of hunger and fullness.

Hunger Scale Journal – A classic food journal with a section specifically for charting hunger and fullness ratings. Your client can download these at www.EatingWisdom.com, or just send me a quick email for permission to upload it to your website, at karin@eatingwisdom.com. There are several different versions of this journal.

CEP Hunger Scale Journal – Hunger Scale Journal set up to highlight additional assignments: set up for two of the most common assignments I give (and also the most difficult)-- asking clients to eat in a Chosen Eating Place (CEP) and do No Other Activity while eating (NOA). This also comes in two versions.

How to Use Food Journals – Outlines how I typically review the Journals with clients. I almost always use the Hunger Scale Journal or one of its different versions, but occasionally have use of the following Journals. 

Personal Food Inventory – Very basic food journal. Helpful when clients are overwhelmed, overly obsessive about keeping records, or when you simply want to look at the adequacy of their intake.

Lifestyle Diary – A basic behavior modification food diary looking at where, when, what, how much, and with whom a client is eating. Useful beginner’s diary.

"The Core Minimum” Daily Food Choices - This is a very basic food selection guideline that I have used forever, based on the Basic Four Food Groups. It is an exchange list meal plan, but is not based on caloric equivalents.

Meal Patterns Guide – Use this form to create a meal plan. Prompts for 3 meals and 3 snacks. Area is provided to write out 2 sample menu options to match the meal plan.

Meal Options Form – Use to create 7 different suggestions each for breakfast, lunch, dinner, and a snack, in session or as homework.

Food Acceptance/ Fears Survey – Use to assess client’s relationship with different foods and food groups. In Word format so that you can add and delete foods as best works for your practice and geographical location.

Behavior Change Contract - A simple contract that looks at a behavior change goal and breaks it into smaller components.

Affirmative Action Form – A take off from the Behavior Change Contract, with the addition of prompts for daily affirmation around behavior change.

ADMINISTRATIVE FORMS

Nutrition Therapy Progress Note - This quick and easy form is completed with information on your session to provide the referring therapist, doctor, etc., with immediate feedback. In Word.

Receipt for Nutrition Counseling – Receipt for client so they can submit your sessions to their insurance company using the 2017 ICD-10-CM Diagnosis Codes. In Word.

Transmittal and Accounting Form –Keep track of client payments and use as the information source for all billing. I was not able to create a form that would meet everyone’s needs, but the form is so critical, I wanted to include it. I decided to include the version I use now with instructions as to how I use it, with the hopes you can alter it to fit your needs. In Word

Past Balance Reminder and Payment Form Letter – Example of letter to send clients with past due balances. In Word.

Payment Authorization Form via mail – Form for client so they can make payment over the phone, by fax or mail. In Word.

Permission to Tape Counseling Sessions - To secure client’s permission to tape counseling sessions for supervision and review. In Word.