Forms

Below are our commonly requested forms. Feel free to print out the forms that you need.

Printable Food Record Journals

Food Record Journal  (full page)
Food Record Journal
(half page)

Release of Information Forms

Need to share your health records? Please complete the form for the state in which you are receiving treatment services.

Minnesota (MN) Release of Information
Ohio (OH) Release of Information

Washington (WA) Release of Information

Insurance Verification

It's important that you understand the services that your insurance will cover. We've created the below tool to help guide you through the insurance verification process. This tool includes everything you will need to have ready for the phone call and every question to ask the insurance representative about your coverage.

Insurance Verification Tool

Intake Forms

Before you get started with services at The Emily Program, we have some paperwork for you to complete. These forms include various documents that help us gather the important information we need from you to begin treatment. They also describe policies and operations that define the way The Emily Program provides care.

Please click on the state where you will be receiving treatment to print and complete the documents according to the instructions. We ask that you bring your completed forms to your first appointment.