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ED Group Intake

  • 1
    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
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  • 2
    Please select one of the following options
    • 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
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  • 3
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  • 4
    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
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  • 5
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  • 6
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  • 7
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  • 8
    Select all that apply
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  • 9
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  • 10
    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
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  • 11
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  • 12
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  • 13
    Please list below. Skip if not applicable
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  • 14
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  • 15
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  • 16
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  • 17
    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
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  • 18
    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
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  • 19
    At this time, the program is open to residents of Ontario, Alberta, and British Columbia.
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  • 20
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  • 21
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  • 22
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  • 23
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  • 24
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  • 25
    At this time, the program is open to residents of Ontario, Alberta, and British Columbia.
    Please Select
    • Please Select
    • AB
    • BC
    • ON
    Please Select
    • Please Select
    • 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
    • Curaçao
    • 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
    • United States
    • 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
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  • 26
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    Pick a Date
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  • 27
    Please provide name, phone, email, and relationship to you
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  • 28
    Please provide your Family Doctor's address or clinic name if that information is available or write NA to skip
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  • 29
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  • 30
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  • 31
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  • 32
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  • 33
    Name and area/region
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  • 34
    Name and area/region
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  • 35
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  • 36
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  • 37
    Layla respects your right to privacy. Please read our policy to understand how we collect and use personal information
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  • 38
    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 $870 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. Additionally, Layla currently offers funding for this program through CCRW for owners and employees of hard-hit small businesses. Please ask your Program Coordinator for more information or email groups@layla.care
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  • 39
    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
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  • 40
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  • 41
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