About Me Form

1About You

2Binge Eating

3Eating habits

4Body image

5Other

6Your recovery

7Emergency Contact

Please 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 you
Your name
Age bracket
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 Book

Let'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?
How 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 helpful

Are 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 name
Emergency contact number

Legal Agreement
Description: Coaching is a partnership (defined as an alliance, not a legal business partnership) between Binge Code (Mind Free LTD), our Coaches and the Client in a thought-provoking and creative process that inspires the client to maximise personal and professional potential. Client Responsibilities: 1. Client is responsible for creating and implementing his/her own physical, mental and emotional well-being, decisions, choices, actions and results. As such, the Client agrees that the Coach is not and will not be liable for any actions or inaction, or for any direct or indirect result of any services provided by the Coach. Client understands coaching is not therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease. 2. Client understands that coaching is not to be used as a substitute for professional advice by legal, mental, medical or other qualified professionals and will seek independent professional guidance for such matters. If Client is currently under the care of a mental health professional, Coach will recommend that Client inform the mental health care provider. 3. Client agrees to communicate honestly, be open to feedback and assistance and create the time and energy to participate fully in the program. Limited Liability: Except as expressly provided in this agreement, the Coach makes no guarantees or warranties, express or implied. In no event will the Coach be liable to the Client for consequential or special damages. By signing this you are also agreeing to our Terms and Conditions: Our coaching program is not intended to diagnose, treat, cure or prevent any condition or disease. Please consult with your own physician or health care practitioner regarding the suggestions and recommendations made at BingeCode.com. [BingeCode.com](http://bingecode.com/) (Mind Free LTD) nor its directors, or anyone else who works for [BingeCode.com](http://bingecode.com/), will be liable for damages arising out of or in connection with the use of this site, our books, online courses or coaching program. This is a comprehensive limitation of liability that applies to all damages of any kind, including (without limitation) compensatory, direct, indirect or consequential damages, loss of data, income or profit, health problems, loss of or damage to property and claims of third parties. It is important to realize that the information that appears on the [BingeCode.com](http://bingecode.com/) website is not meant as replacement for proper care from a doctor, therapist, nutritionist, etc. Information provided by [BingeCode.com](http://bingecode.com/) is not a substitute for medical treatment or psychological care. It is vital that you talk with your physician and a qualified mental health professional regarding eating disorder symptoms and treatment. Minors should consult with a legal guardian or other adult when considering treatment and providers. The diagnosis and treatment of eating disorders or any other mental illness requires the attention of a physician or other properly qualified mental health professional. All information and materials on this website are protected by copyright. Copyright resides with the United Kingdom While we hope the Coaching Services are beneficial to you, you understand, agree and acknowledge that they may not be the appropriate solution for everyone’s needs and that they may not be appropriate for every particular situation. Disclaimer of Warranty and Limitation of Liability YOU HEREBY RELEASE US AND AGREE TO HOLD US HARMLESS FROM ANY AND ALL CAUSES OF ACTION AND CLAIMS OF ANY NATURE RESULTING FROM THE COACHING SERVICES OR THE PLATFORM, INCLUDING (WITHOUT LIMITATION) ANY ACT, OMISSION, OPINION, RESPONSE, ADVICE, SUGGESTION, INFORMATION AND/OR SERVICE OF ANY COACH AND/OR ANY OTHER CONTENT OR INFORMATION ACCESSIBLE THROUGH BINGECODE.COM. YOU UNDERSTAND, AGREE AND ACKNOWLEDGE THAT THE PLATFORM IS PROVIDED “AS IS” WITHOUT ANY EXPRESS OR IMPLIED WARRANTIES OF ANY KIND, INCLUDING BUT NOT LIMITED TO MERCHANTABILITY, NON-INFRINGEMENT, SECURITY, FITNESS FOR A PARTICULAR PURPOSE OR ACCURACY. THE USE OF THE PLATFORM IS AT YOUR OWN RISK. TO THE FULLEST EXTENT OF THE LAW, WE EXPRESSLY DISCLAIM ALL WARRANTIES OF ANY KIND, WHETHER EXPRESSED OR IMPLIED. YOU UNDERSTAND, AGREE AND ACKNOWLEDGE THAT WE SHALL NOT BE LIABLE TO YOU OR TO ANY THIRD PARTY FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL, PUNITIVE OR EXEMPLARY DAMAGES. YOU UNDERSTAND, AGREE AND ACKNOWLEDGE THAT OUR AGGREGATE LIABILITY FOR DAMAGES ARISING WITH RESPECT TO THIS AGREEMENT AND ANY AND ALL USE OF THE PLATFORM WILL NOT EXCEED THE TOTAL AMOUNT OF MONEY PAID BY YOU THROUGH THE PLATFORM IN THE 3 MONTHS PERIOD PRIOR TO THE DATE OF THE CLAIM. IF YOU ARE THINKING ABOUT SUICIDE OR IF YOU ARE CONSIDERING HARMING YOURSELF OR OTHERS OR IF YOU FEEL THAT ANY OTHER PERSON MAY BE IN ANY DANGER OR IF YOU HAVE ANY MEDICAL EMERGENCY, YOU MUST IMMEDIATELY CALL THE EMERGENCY SERVICE NUMBER (911 IN THE US) AND NOTIFY THE RELEVANT AUTHORITIES. SEEK IMMEDIATE IN PERSON ASSISTANCE. THE PLATFORM IS NOT DESIGNED FOR USE IN ANY OF THE AFOREMENTIONED CASES AND THE COACHES CANNOT PROVIDE THE ASSISTANCE REQUIRED IN ANY OF THE AFOREMENTIONED CASES. If the applicable law does not allow the limitation of liability as set forth above, the limitation will be deemed modified solely to the extent necessary to comply with applicable law. Governing law and jurisdiction Our agreement with you and any dispute or claim arising out of or in connection with it or its subject matter or formation (including non- contractual disputes or claims) shall be governed by and construed in accordance with English law. The parties irrevocably agree that the courts of England and Scotland shall have exclusive jurisdiction to settle any dispute or claim that arises out of or in connection with this agreement or its subject matter or formation (including non-contractual disputes or claims). Only a trained medical professional can diagnose you and tell you what treatment is right for you for your recovery. It is important that you have clearance from a medical professional before coming onboard our coaching program. Eating disorders can be life threatening and it's very important that we take this seriously during your time on coaching. It is coach discretion who they agree to work with or continue to work with. If a coach feels you are no longer fit for our coaching program your coaching will be stopped. On signing up to coaching you are made aware that our service is not a replacement for professional medical intervention. If needed, we are obligated to remove anyone from our coaching program who we feel needs 'professional intervention' and 'not coaching'. This does not happen often, however it does happen from time to time. Again we do this because we have a duty of care for all our clients. Flags that tell our coach that coaching is not right for you: You are feeling very overwhelmed and unable to cope You are mentioning or suggesting suicide or have suicidal thoughts. You are showing signs of depression and/or extreme anxiety Your mental health is declining Your physical health is declining You have another addiction that is interfering with your recovery Someone has pushed you into coaching and you have no interest of engaging with your coach. You are not using your coaching sessions and we do not hear from you You feel everything is too much and too difficult to handle You are using coaching as a replacement for therapy You have recently been admitted to hospital for suicidal thoughts or attempts You suffer with extreme mental health challenges. others signs will also come up from time to time. If we feel you are not fit for coaching you will be sent an email stating that we have to remove you from our coaching service. Any coaching sessions outstanding will be refunded to you and your coaching will be immediately stopped. You will be advised to go to your GP or trained health professional ASAP to seek advice for the best treatment moving forward. If, during this time you feel your mental health is an emergency, you MUST seek professional help ASAP. Please consult with your GP or medical professional. We can provide a range of numbers for you. If a number is not listed, please google your country and available emergency help contact line. Please note our coaches at Binge Code are NOT here to provide an emergency help service and we can NOT provide you with any emergency mental health care you may need. You must seek this through trained professionals or through an emergency service HELP line. Please can you also provide us an emergency contact number that you agree for us to contact should we feel your mental health is in an emergency If we can not get through to this number and we are concerned about your well-being we also have the duty of care to contact authorities on your behalf. Terms of service: Coaching is not a replacement for professional treatment or advice. If you feel your mental health is declining you must let us know as soon as possible and you must also consult with your doctor or trained medical professional. If you feel you are suicidal or having suicidal thoughts you must tell your coach and seek EMERGENCY PROFESSIONAL help ASAP. Your coaching will be immediately stopped. If you feel your mental or physical health is declining you must tell your coach then seek professional help, during this time your coaching will be stopped. You must not discuss medication with your coach Your coach can not treat or diagnose you, only a trained medical professional can do that. You understand that our coaches are not trained therapists or medical professionals, please respect these boundaries. If at any time we feel these have been imposed, you may be asked to leave coaching. You agree to regularly visit your doctor or other trained health professional during your time on coaching for monitoring and mental/physical health check ups. On agreeing to this you agree we can contact your emergency contact number that you agree we can contact should we feel you are having a mental health emergency. if we do not hear from you after several attempts to reach you, your coach will reach out to your emergency contact number provided.
Please sign that you agree with the above terms
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