Survey - Remote Chat Log 2019v1 - National Eating Disorders Association

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Question - Required - Method of Contact

Question - Not Required - Interaction type (if applicable)

Question - Not Required - Requested Translator

Question - Not Required - Language requested

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Question - Required - Volunteer Name/Initial

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Question - Required - Contact Name

Question - Not Required - Contact Phone

Question - Not Required - Contact Email

Question - Not Required - Mailing Street

Question - Not Required - Mailing City

Question - Not Required - Mailing State

Question - Not Required - Mailing Zip code

Question - Not Required - Country

Question - Not Required - Time Zone

Question - Not Required - The contact is reaching out for

	Themselves
	Their friend
	Their family member
	Their parent
	Their sibling
	Their child
	Their partner/spouse
	Their client
	Their student
	Their coworker

Question - Not Required - Contact is reaching out for (other)

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Question - Required - Gender of contact

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Question - Required - Gender of the person affected

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Question - Required - Age range of person affected

Question - Not Required - Ethnicity of person affected

	African American
	Asian/Pacific Islander
	Hispanic/Latino
	Native American
	White
	Other
	Prefer not to say
	Unknown

Question - Not Required - Sexual orientation of person affected

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Question - Required - Stage of change of the person affected

Question - Not Required - Presenting ED issues

	Binge eating
	Restricting
	Vomiting
	Excessive exercise
	Laxative abuse/use
	Compulsive overeating
	Chewing and spitting
	Ingesting non-food substances

Question - Not Required - Other presenting ED issues

Question - Not Required - ED diagnosis

	Anorexia Nervosa
	Bulimia Nervosa
	Binge Eating Disorder
	OSFED
	ARFID
	Rumination Disorder
	Pica

Question - Not Required - Other ED diagnosis

Question - Not Required - Co-occurring issues

	Depression
	Anxiety
	Other mood disorder
	OCD
	Suicide/suicidality
	Self-harm
	PTSD/Trauma
	Personality Disorder
	Substance abuse

Question - Not Required - Directed contact to

	Crisis Text Line
	Suicide Prevention Lifeline
	S.A.F.E.
	RAINN
	Medical Care (for medical emergencies)
	18Percent
	Recovery Record

Question - Not Required - Directed contact to (other)

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Question - Required - Volunteer Action to Take

Question - Not Required - ASAP (with supervisor approval)

Question - Not Required - Level of care requested

	Inpatient
	Residential
	Partial hospitalization program
	Intensive outpatient program
	Outpatient
	In-person support groups
	Online support groups

Question - Not Required - If outpatient, discipline requested

	Psychologist
	Social worker
	Counselor
	Online therapists
	Psychiatrist
	Dietitian/Nutritionist
	Online dietitian/nutritionist
	Medical doctor

Question - Not Required - Travel distance requested (in minutes or miles)

Question - Not Required - Insurance requested

	Medicare
	Medicaid
	Tricare
	Private insurance
	Sliding scale

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Question - Required - Notes

Question - Not Required - What was requested

	Treatment options
	Information
	Insurance issues support
	Financial issues support
	First time talking to someone about their eating concerns

Question - Not Required - Other requests

Question - Not Required - Provided disclaimer

Question - Not Required - Please list all the treatment options you provided

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Question - Required - Request Status

Question - Not Required - Voicemail consent was given (if applicable)