Patient Information
Name: _________________
Date: _________________
Primary Care Provider: _________________
Treatment Team Contacts
- Primary Psychiatrist: _________________
- Therapist/Counselor: _________________
- Nutritionist/Dietitian: _________________
- Emergency Contact: _________________
Treatment Goals
Short-term Goals (1-3 months)
- Stabilize eating patterns
- Establish regular meal schedule
- Begin addressing underlying emotional factors
Long-term Goals (3-12 months)
- Maintain healthy weight range
- Develop sustainable coping mechanisms
- Improve body image and self-acceptance
Meal Planning Guidelines
Daily Requirements
- Meals per day: 3 main meals + 2-3 snacks
- Minimum caloric intake: _________________
- Required food groups per meal: _________________
Meal Schedule
- Breakfast: _________ (time)
- Morning Snack: _________ (time)
- Lunch: _________ (time)
- Afternoon Snack: _________ (time)
- Dinner: _________ (time)
- Evening Snack: _________ (time)
Monitoring Protocol
Physical Health Monitoring
- Weekly weigh-ins: □ Yes □ No
- Vital signs monitoring frequency: _________________
- Laboratory tests frequency: _________________
Psychological Monitoring
- Therapy sessions frequency: _________________
- Group therapy participation: _________________
- Mood tracking method: _________________
Crisis Management Plan
Warning Signs
- Significant weight changes
- Return of disordered eating behaviors
- Increased anxiety or depression
- Social withdrawal
Emergency Contacts
- Crisis Hotline: _________________
- Local Emergency Room: _________________
- Treatment Team After Hours: _________________
Recovery Strategies
Coping Mechanisms
- Mindfulness exercises
- Stress management techniques
- Body image exercises
- Social support utilization
Progress Tracking
- Weekly progress journal
- Symptom monitoring log
- Behavioral goals checklist
Agreement
I understand and agree to participate in this management plan:
Patient Signature: _________________ Date: _________________
Provider Signature: _________________ Date: _________________