Linda J. Cooke, LCSW
MAKING PEACE WITH FOOD: MINDFULNESS SKILLS FOR OVERCOMING OVEREATING
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
How did you learn about or get referred to this class?
Are you currently in therapy?
Yes
No
If yes, with whom? For how long? What is your diagnosis? What is your current status/symptoms?
Briefly describe your eating patterns/behaviors; including purging, restricting, compulsive exercise, laxative use, etc.
Are you currently using any substances/drinking alcohol? If yes, please describe what you are using and amount of use:
Please describe your weight loss and diet history. When and how have you been successful? What has led to weight gain and compulsive eating?
Have you ever been hospitalized for mental health reasons? When? Where? Most recent? Why? How long?
Have you ever been or are you currently feeling hopeless about your situation?
Yes
No
Have you ever been suicidal and made an attempt to take your life? Please explain if yes
Do you currently feel suicidal or have thoughts of suicide? Please explain if yes
If yes, do you have a plan? Please explain if yes.
Do you engage in self-injurious behaviors? Please explain if yes.
Please describe your current living situation.
Are you currently employed? If yes, indicate number of hours.
Please describe your current Relationships/Family/Supports:
What are your strengths?
What do you hope to gain from attending this group?
Personal Assessment
Do I get enough rest?
Yes
No
Am I in good health?
Yes
No
Do I engage in moderate exercise three or more times per week?
Yes
No
Do I have task-related stress?
Yes
No
Do I have supports?
Yes
No
Am I capable of handling intense emotions?
Yes
No
Do I have negative beliefs about handling emotions?
Yes
No
Do I drink caffeine?
Yes
No
*Amount of caffeine per day
Do I go more than three hours between meals/snacks?
Yes
No
Do I eat a lot of sugary products?
Yes
No
Do I eat a lot of high glycemic index carbohydrates?
Yes
No
My strongest emotional characteristic is:
Irritable/Angry
Happy/Serene
Anxious/Worrier
Sad/Depressed
Submit
Should be Empty: