Emma Murphy MIACP – Psychotherapist specialist in disordered eating

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LGBTQAI Client Pre Assessment Form

Eating Freely Assessment Questionnaire

Please fill in this form. Your answers are only shared with the Eating Freely Coaches who are supporting you during this 6 month experience.

Your Name

How long have you been struggling with food, your weight and/or your body image?

Have you had support before this? If yes, what sort of support and was it helpful?

Yes

No

If you answered 'Yes', can you tell me what type of help, for how long, and if you felt it helped or not?

..and if it didn't help, why do you think it didn't?

Joining our online community now, what is your single biggest challenge when it comes to food, weight or your body?

One year from now, what would you like to tell us has changed for you - what will life look like if that single biggest challenge was resolved?