interview

Name: Diamond Moore                 Address _____700 south 43rd street_____________________________

City/State____Grand Forks, ND__________ Telephone________701-123-4567_______________

Birthdate _____12/25/1999_______ Race: __African American   Gender

identified:__Female___ Marital Status:                 Single ­

Occupation ____waitress________________ Education ­­_Dance Major___________________________

Partner’s name____N/A_______________ Age __N/A__ Occupation __N/A________

Household members/relationship__N/A ______________________________

Presenting Problem ____Eating Disorder__________________________________________

Referred by ­­­­­­____Instructor_________________

Emergency Contact _____Mother_________ Phone number __7013175189____________________

Follow up appointment ______NA______________________ Referrals   N/A              

Goals ____Recognize my obsession with my weight is detrimental to my health and career and be more confident in my body image and better manage my life to decrease depression and anxiety