Note to individual completing this form: if the information in any item is "unknown" or "unavailable at this time," please indicate such and do not just leave items blank
Please bring with you copy of custody or legal guardianship papers if applicable
The following might be considered "unusual" weight loss:
Young children: 2 pounds in 3 months or 5 pounds in 6 months
Teens: 5 pounds in 1 month or 10 pounds in 6 months
The following legal issues MAY have some effect on how we create a service plan for you and your family. Please answer below.