About Me Form 1About You2Binge Eating3Eating habits4Body image5Other 6Your recovery7Emergency ContactPlease take 10 minutes to complete this form before working with your coach. The better we understand your situation, the more we can help you. Need help? Email support@bingecode.com About youYour nameAge bracket18-2525-3535-5050+Email Time zone you reside in (nearest city or timezone)Have you read any of these books? The Binge Code Book The Bulimia Help Method Book Brain over Binge BookLet's explore your binge eating behaviour.Can you describe your feelings leading up to a binge episode?If possible, can you list some of your binge triggers?What time of day would you normally binge on food?How long would a typical binge episode last?How do you feel afterwards?Do you try to counter a binge episode by fasting, working out, purging, use laxatives etc?How would you describe your eating habits when you are NOT engaging in binge eating/purging? (for example: do you diet? restrict food groups? overeat? try to eat healthy? eat in a structured way? etc)Are you able to eat from all of the main food groups? (proteins, fats, carbs)Do you have to restrict any food groups for health conditions?Do you count calories? Would you consider yourself underweight, average weight or above average weight?UnderweightAverage weightOver weightHow do you feel about your body?Do you have any other health conditions?Have you ever tried to recover or experienced phases of recovery before? If so, what worked for you?What is your primary motivation for recovery at present?What would you say your biggest barrier at present?Is religion or spirituality an important support to your recovery?Please use this space to provide your coach with any further information that you think would be helpfulAre you able to provide us with an emergency contact number? (we've never had to call an emergency number yet, but it's always good to have one)Emergency contact nameEmergency contact numberWould you like a copy of this form sent to your email address? Yes No thanks
