Online Intake Form

All information submitted via this form will be kept confidential and private by Magnolia Creek, in accordance with our Privacy Policy. Please note that upon submitting this form, the website will generate an automatic email reply to the provided email address with a copy of your responses for your records.

Please note that all fields with a red asterisk (*) are required.

Your Contact Information

Title:

First Name: *

Last Name: *

State, if living in the U.S.:

Country, if living outside U.S.:

Email Address: *

Daytime Phone: *

Cell or Evening Phone:

Potential Client Information

Are you inquiring for yourself or another individual?:

Myself

Someone else

If someone else, please specify your relationship to her:

Individual's First Name:

Individual's Last Name:

Individual's State, if living in the U.S.:

Individual's Country, if living outside U.S.:

Marital Status:

Number of Children:

Employment Status:

Date Last Worked/in School:

If no longer employed or in school.

Date of Birth/Age:

Current Height:

Current Weight: lbs

Insurance Information

Fill in insurance information if known.

Insurance Provider:

Group Number:

Policy Number:

Provider Phone Number for Mental Health Benefits:

Additional Information

What is your primary concern for contacting us?:

Anorexia

Bulimia

Exercise Addiction

Other (please specify below)

If other, please specify:

How long has this been a concern?:

How did you hear about Magnolia Creek?:

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Online Intake Form

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