ED Group Intake

1
Which challenges you are facing related to eating* This field is required.
Please select at least one option from the list
Anorexia Nervosa
Avoidant Restrictive food intake disorder
Binge Eating Disorder
Binge Eating
Bulimia Nervosa
Compulsive overeating
Diabulimia (Prescription insulin induced weight loss)
Discomfort eating around others
Emotional eating
Extreme concern with body size and shape
Extreme concern with musculature and physique
Food rituals
Frequent checking in the mirror for perceived flaws in body appearance
Frequent dieting
Orthorexia (obsession with healthy eating)
Pica
Preoccupation with weight, food and control of food, calories, carbohydrates, fat grams, and dieting
Refusal to eat certain foods
Restrictions against categories of food (e.g. no carbohydrates etc)
Rumination disorder
Selective Eating Disorder
Skipping meals or taking small portions of food during meals
2
What is the main area you are looking for support with?* This field is required.
Please select one of the following options
ADHD (strategies to manage)
Aging
Anger management
Anxiety (incl. panic, GAD, and social)
Behavioral Addiction
BPD or related symptoms
Coping with chronic pain or illness
Coping with concussion or ABI
Court-mandated
Eating disorder
Emotional eating/other eating challenges
Emotion regulation
Depression, sadness, or low mood
Dissociation
Family conflict
Fertility Issues
Grief or loss
Impacts of racism or discrimination
Imposter Syndrome
Immigration-related life challenges
Life transitions/uncertainty
OCD-related symptoms
Personality disorder other than BPD
Phobia(s)
Pre- or Post-Natal challenges
Psychosis
Relationship challenges
Intimate partner abuse
Self-esteem
Self-exploration
Sexual abuse/assault (including childhood sexual abuse)
Sexual or gender identity
Sexual dysfunction
Skin-picking or hair-pulling
Sleep concerns
Stress/burnout
Substance use or addiction
Trauma (single-incident)
Trauma (multiple incident or ongoing)
Work or school issues
3
(Optional) What other areas are you also looking for support with?
Click here to select or NEXT to skip
ADHD (strategies to manage)
Aging
Anger management
Anxiety (incl. panic, GAD, and social)
Behavioral Addiction
BPD or related symptoms
Coping with chronic pain or illness
Coping with concussion or ABI
Court-mandated
Eating disorder
Emotional eating/other eating challenges
Emotion regulation
Depression, sadness, or low mood
Dissociation
Family conflict
Fertility Issues
Grief or loss
Impacts of racism or discrimination
Imposter Syndrome
Immigration-related life challenges
Life transitions/uncertainty
OCD-related symptoms
Personality disorder other than BPD
Phobia(s)
Pre- or Post-Natal challenges
Psychosis
Relationship challenges
Intimate partner abuse
Self-esteem
Self-exploration
Sexual abuse/assault (including childhood sexual abuse)
Sexual or gender identity
Sexual dysfunction
Skin-picking or hair-pulling
Sleep concerns
Stress/burnout
Substance use or addiction
Trauma (single-incident)
Trauma (multiple incident or ongoing)
Work or school issues
4
How long have you been dealing with these challenges?* This field is required.
Recently (one month or less)
Within 2-6 months
6-12 months
12+ months
5
How old were you when you first began to struggle with these concerns?* This field is required.
6
How much are these issues impacting your day-to-day (mood, relationships, work, health)?* This field is required.
Starting to impact/impacting now and then
Moderate/frequent impact
Significant/regular impact
Serious and constant impact
7
Have you struggled with these feelings, thoughts, and/or behaviours continuously since they began?* This field is required.
Yes
No
Yes - On and Off
8
Have you previously received any type of mental health services for your eating-related concern?* This field is required.Select all that apply
No
Psychiatric services
Individual therapy
Couples/family therapy
Group therapy
9
Have you received a psychological diagnosis from a qualified healthcare professional?
Select one or more here or skip
ADHD (strategies to manage)
Adjustment disorder
Agoraphobia
Anorexia Nervosa
Antisocial personality disorder
Anxiety (Unspecified)
Any diagnosis related to neglect or abuse
Any Psychotic disorder
Any Sexual Disorder
Any Sleep Disorder (Incl. Insomnia)
Any Substance Use Disorder
Attention-deficit/hyperactivity disorder
Autism spectrum disorder
Binge-eating disorder
Bipolar Disorder (Type I or II)
Body dysmorphic disorder
Borderline Personality Disorder
Bulimia Nervosa
Conduct disorder
Delusional disorder
Depression (Unspecified)
Dissociative identity disorder
Enuresis
Gambling disorder
Gender dysphoria
Generalized Anxiety
Hoarding disorder
Health anxiety
Intellectual disability
Intermittent explosive disorder
Kleptomania
Major Depressive Disorder
Narcissistic personality disorder
OCD
Oppositional defiant disorder
Overweight or obesity
Panic Disorder/Panic attacks
PDD (dysthymia)
Premenstrual dysphoric disorder
PTSD
Pyromania
Reactive attachment disorder
Separation anxiety disorder
Skin-Picking or Hair-Pulling
Social Anxiety
Specific learning disorder
Specific phobia
Tourette’s disorder
Unspecified personality disorder
10
Are you currently taking any psychiatric medications?* This field is required.
No
Recently started & helpful
Recently started & not clear if helpful
> 3 months & helpful
> 3 months & not that helpful
11
Are you in touch with a physician about your mental health / medications?* This field is required.
No
Irregularly
A few times per year
Monthly or more
12
How often do you drink alcohol?* This field is required.
Daily
Weekly/Monthly
Infrequently/Never
13
How often do you engage in recreational drug use?* This field is required.
Daily
Weekly/Monthly
Infrequently/Never
14
Have you received a diagnosis of a developmental disorder?Please list below. Skip if not applicable
15
Layla is not a crisis service* This field is required.If you or someone you know is in crisis or at risk of serious harm towards yourself or others, call 911 or go to an emergency room
16
Which Eating Disorders Group are you interested in?* This field is required.
Wednesdays starting January 26th 2022: 6:00-7:30pm EST - 12 Sessions
Thursdays starting March 3rd 2022: 6:00-7:30pm EST - 12 Sessions
17
Do you feel comfortable being in a group of up to 8-12 participants?* This field is required.This is an online video group, but you can choose to only display your first name in the group. Everyone will be asked to commit to confidentiality
Yes
No
Maybe. Want to talk to Layla/the therapist first
18
Plan on using benefits?This group will be delivered by a Registered Social Worker or Registered Psychotherapist. Please check your insurance or let us know if we can help with that
Yes
No
Not Sure
19
Program available to residents of Ontario, Alberta, and British Columbia, 18 years or older* This field is required. At this time, the program is open to residents of Ontario, Alberta, and British Columbia.
20
Name* This field is required.
First Name
Last Name
21
What pronouns do you use
She/her/hers
He/him/his
They/them/theirs
22
Email* This field is required.
example@example.com
Confirm Email
23
Phone Number* This field is required.
(###) ###-####
24
Address* This field is required.At this time, the program is open to residents of Ontario, Alberta, and British Columbia.
Street Address
Street Address Line 2
City
Please Select
Please Select
AB
BC
ON
Province
Postal Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
25
Date of Birth* This field is required.
Date
Year
Month
Day
26
Emergency Contact* This field is required.Please provide name, phone, email, and relationship to you
27
Family Doctor Clinic LocationPlease provide your Family Doctor's address or clinic name if that information is available or write NA to skip
28
For continuity of care, can we let your Family Doctor know the name of your enrollment in this program?* This field is required.
Yes
No
29
Family Doctor Name
First Name
Last Name
30
Family Doctor Phone Number* This field is required.
(###) ###-####
31
How did you hear about us?
Family or friend
Online search
Family Doctor
Other health/wellness professional
32
Family DoctorName and area/region
33
Referring ProviderName and area/region
34
Health/Wellness Professional Name* This field is required.
First Name
Last Name
35
Health/Wellness Professional designation* This field is required.
Nurse Practitioner
Psychiatrist
Psychologist
Social Worker/Psychotherapist
Naturpath
Dietitian/Nutritionist
Other healthcare provider
Other community worker
General Practitioner
36
Privacy of your information* This field is required.Layla respects your right to privacy. Please read our policy to understand how we collect and use personal information
37
Program not publicly funded | Typically eligible under benefits* This field is required.Layla's intake call is free. Fees for subsequent therapy sessions apply. This program is not covered by public health insurance. This program is offered at a total of $853 including taxes, which covers all 12 sessions / 18 hours of the program. This group will be delivered by a Registered Social Worker or Registered Psychotherapist. Please check your insurance or let us know if we can help with that.
38
Groups
ED Skills Group
39
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