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Prospective Patient Form

Start Your Eating Recovery Journey Today

Our admissions process begins with a comprehensive assessment of each patient’s medical, psychological and sociocultural history, as well as thorough verification of insurance benefits. Together with guidance from the Clinical Assessment team, this information helps patients and families make informed decisions about pursuing and financing eating disorder treatment.

Please complete the form below to provide your information to our Clinical Assessment team. By submitting this information, you are consenting to have a clinical team member follow up with you as well as have our business office check your insurance benefits.

Prospective Patient Form
1 Instructions
2 Patient Information
3 Insurance Information
4 Outpatient Team


This information should be readily available to you by reviewing your insurance card. If you cannot locate your insurance information, we encourage you to contact your insurance company and complete this form following that conversation. Please note Eating Recovery Center cannot begin the benefits verification process if any Insurance Information fields are empty upon submission. It will be the responsibility of the patient to contact the Clinical Assessment department with any missing information, after which they will begin processing insurance benefits.

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Eating Recovery Center is accredited through the Joint Commission. This organization seeks to enhance the lives of the persons served in healthcare settings through a consultative accreditation process emphasizing quality, value and optimal outcomes of services.

Organizations that earn the Gold Seal of Approval™ have met or exceeded The Joint Commission’s rigorous performance standards to obtain this distinctive and internationally recognized accreditation. Learn more about this accreditation here.

Joint Commission Seal
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