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Body Acceptance Group
Interested in joining our Body Acceptance Group? Fill out the inquiry form below to enroll.
The group is limited to those 18 years and older.
Name
*
First
Last
Email
*
Phone #
*
Date of Birth
*
Please check if you have one of the below insurance types. If not, please be advised that you can join us as a self pay client.
*
Anthem Blue Cross Blue Shield
Aetna
Cigna
Health Partners
United Healthcare / UMR
Health Payment Systems
Self Pay ($45/Group)
Do you currently have an outpatient therapist? If so, what is their name?
*
Do you currently have an outpatient dietitian? If so, what is their name?
*
Have you ever participated in inpatient, residential, or partial hospitalization or intensive outpatient program? If so, please provide dates.
*
Are you currently coping with any of the following:
Eating Disorder
Chronic Dieting
Disordered Eating
Are you currently or ever been an active client of Elle for any of the below services?
*
Yes
No
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