Dear Student(s):
We are pleased to have you join us and look forward to meeting all of you!
You have recently registered for You & Food, jointly offered by Counselling Services and Health Services.
We are requesting that you complete the attached short questionnaire prior to the first meeting to
ensure that this group fits with your expectations. Attending groups or a professional development
workshop may be a new experience for you or you may be uncertain, so please bring your questions and
ideas to Sandy.
Please print and bring the completed questionnaire to Sandy Ace, Health Services Dietitian, in Health
Services 107 for a brief (10-15 minute) meeting during one of the following times (no appointment
necessary):
•
Wednesday Jan. 25 from 1:30 to 4:00
•
Friday Jan. 27 from 9:30 to 12:00
If you are unable to meet with Sandy during this time, please contact her at [email protected] or 519888-4567 x35599 to make alternate arrangements. The questionnaire will also be available in HS 107
and can be filled out there if you prefer. The information you provide is confidential.
You & Food Questionnaire
Name:___________________________
Date:______________
1.
What interests you about the group?
2.
What do you hope to get out of the group?
3.
How did you find out about the group?
4.
What kind of eating behaviour challenges do you struggle with?
5.
How long has it been a problem for you?
6.
Have you ever received professional help before for your eating
behaviours? Any formal diagnosis?
7.
Are you currently working with a counsellor, therapist, or a doctor?
If so, who?
8.
Are you currently taking medication related to your eating problem?
If so, what kind?
9.
Have you had any hospitalizations for eating-related difficulties?
10.
Is there anything that you can think of that would prevent you from
regularly attending the group?
11.
Does anyone know about your difficulties? How have they responded?
12.
Do you have any questions?
Note: This information is for screening purposes only and is strictly confidential. Questionnaire will not
be kept on file but will be destroyed according to protocol for handling confidential documents.
Thank you for your interest and participation!