Do I need medical clearance before treating a client with an eating disorder in outpatient therapy?

Medical safety determinations are made by medical providers, not therapists — but you are responsible for documenting that the determination happened. Best practice for restrictive, purging, or rapidly changing presentations is to require a recent medical evaluation (or obtain one early in treatment) and to document the coordination: the release of information, the date of the medical visit, who is monitoring weight and vital signs, and the agreed communication plan. If a client refuses medical evaluation, document your recommendation, the client's refusal, your informed-consent discussion of the risks, and your decision-making about whether outpatient therapy remains appropriate.

Should I weigh clients myself, and how do I document weight?

This depends on your role, setting, and treatment model. Many outpatient therapists do not weigh clients and instead document that weight monitoring is delegated to the medical provider or dietitian, including how often and how results are shared. If you do take weights (common in FBT and some CBT-E protocols), document the protocol — open or blind weights, frequency, and how the data informs treatment decisions. Whichever approach you use, the record should never be silent on who is tracking weight in a restrictive or purging presentation; an audit or adverse event will look for exactly that.

Which screening instruments should I document in an eating disorder assessment?

Commonly documented instruments include the EDE-Q (Eating Disorder Examination Questionnaire), the EAT-26, the SCOFF as a brief screen, and the NIAS for avoidant/restrictive presentations, alongside general measures such as the PHQ-9 and GAD-7 given high comorbidity. Document the instrument name, date administered, score, and a plain-language interpretation. No questionnaire makes the diagnosis by itself — document that scores were integrated with the clinical interview, collateral information, and medical data.

How do I document an eating disorder assessment for an adolescent?

Include caregivers as informants and document their observations separately from the adolescent's self-report — discrepancies are common and clinically meaningful, since minimization is a core feature of restrictive eating disorders. Document growth-curve history rather than a single weight (pediatric providers assess weight relative to expected growth trajectory), the family's mealtime observations, and the consent/assent structure. If you are recommending family-based treatment (FBT), document the rationale and the caregivers' capacity to participate.

What if the client denies a problem but collateral information and medical data suggest a serious eating disorder?

Document both data streams without forcing agreement between them. Record the client's self-report accurately (including denial or minimization), then record the objective and collateral findings — weight trajectory, medical findings communicated by the physician, family observations — and state your clinical reasoning about the discrepancy. Limited insight is itself a documented clinical finding that bears on diagnosis, risk, and level of care. Avoid documenting the client as 'lying'; use descriptive language such as 'client's self-report is discrepant with collateral and medical data, consistent with limited insight into illness severity.'

When should I document a referral to a higher level of care?

Document a level-of-care analysis whenever medical instability is reported by the medical provider, weight or behaviors are worsening despite adequate outpatient treatment, safety concerns escalate, or the client cannot interrupt behaviors between weekly sessions. Your note should show the criteria you weighed (medical status per the physician, symptom trajectory, psychiatric risk, motivation, support system), the options considered (IOP, PHP, residential, inpatient), what you recommended, and the client's response. If the client declines a recommended higher level of care, document the informed-refusal discussion and your ongoing monitoring plan.

Eating Disorder Assessment: Template, Example & Documentation Guide

Assessment Reports|15 min read|Updated 2026-07-18|Clinically reviewed

What Is an Eating Disorder Assessment?

An eating disorder assessment is a structured clinical evaluation that documents the presence, severity, and functional impact of disordered eating — restriction, binge eating, compensatory behaviors, body-image disturbance, and avoidant/restrictive intake — and integrates psychological findings with medical data supplied by the client's physician. This guide includes a blank template and a fully written, fictional example showing what a finished assessment reads like, along with step-by-step guidance for each domain.

Eating disorder assessments differ from most mental health intakes in one critical way: they are inherently multidisciplinary documents. Anorexia nervosa has one of the highest mortality rates of any psychiatric disorder, and much of that risk is medical — cardiac, electrolyte, and refeeding-related complications that a therapist neither diagnoses nor manages. A defensible assessment therefore documents two parallel tracks: your own psychological evaluation, and your coordination with the medical providers who evaluate and monitor physical risk. The assessment is where that coordination structure is established and recorded.

This page covers assessment and documentation practice for licensed clinicians. It is not medical guidance, and nothing in it replaces evaluation by a physician or other medical provider.

When You Need It

At intake for any client presenting with disordered eating, weight or shape preoccupation, or a referral question involving an eating disorder
When screening in general practice surfaces concerns (e.g., a positive SCOFF, unexplained weight change, or a physician referral)
Before beginning a structured eating disorder treatment such as CBT-E, FBT, or DBT adapted for eating disorders
When determining or justifying level of care — outpatient, IOP, PHP, residential, or inpatient
At step-down from a higher level of care, to establish the outpatient baseline and relapse-monitoring plan
At reassessment intervals, or when the clinical picture changes (new purging behavior, accelerating weight loss, new medical findings)
When insurance requires documentation of medical necessity for eating disorder treatment

Key Components

Referral Information and Presenting Concerns

Document who initiated the referral (self, family, physician, dietitian, school, prior treatment program) and the specific concerns. Eating disorder referrals frequently originate with someone other than the client, and the client's own account of the problem may differ sharply from the referrer's. Record both versions. Note the client's stated goals — "my parents made me come" is itself clinically important data about motivation and insight.

Weight and Eating History

Document the longitudinal course, not just the current snapshot:

Weight history: highest and lowest adult (or growth-curve) weights, weight at symptom onset, current reported weight and how recently and by whom it was measured, and the trajectory over the past 3–6 months. For adolescents, note deviation from the established growth curve as reported by the pediatric provider.
Dieting and restriction history: age of first diet, triggering events, progression of rules and restriction, current intake pattern (a non-judgmental 24-hour recall is often the most useful documentation device), foods avoided, fluid intake, and rituals around eating.
Binge eating: objective vs. subjective episodes, frequency, duration, triggers, sense of loss of control, and secrecy.
Compensatory behaviors: self-induced vomiting, laxative/diuretic/enema use, diet pills, insulin omission in diabetic clients, compulsive exercise, fasting — with frequency, duration, and most recent occurrence for each.
Body image: the degree of overvaluation of shape and weight in self-evaluation, body checking and avoidance behaviors, and the client's response to weight change.

Screening and Standardized Instruments

Document instrument, date, score, and interpretation. Common choices include the EDE-Q, EAT-26, SCOFF (brief screen), and NIAS (for avoidant/restrictive presentations), plus PHQ-9, GAD-7, and a structured suicide risk screen given elevated comorbidity and suicide risk in this population. State explicitly that instruments were interpreted alongside interview, collateral, and medical data.

Medical-Risk Documentation and Coordination

This is the section that most distinguishes an eating disorder assessment from a standard intake, and it is documentation of coordination, not of medical judgment. Therapists do not interpret ECGs or electrolytes; they document that qualified providers are doing so, and what those providers communicated. Your assessment should record:

Medical home: the client's physician or pediatric provider, date of the most recent medical evaluation, and whether that evaluation addressed the eating disorder specifically.
Release of information: that an ROI for the medical provider (and dietitian, if involved) was signed, or the client's refusal and your response to it.
Findings as communicated to you: vital signs, weight, orthostatic changes, labs, or other findings as reported by the medical provider, with attribution and date — e.g., "Per Dr. [name]'s office (03/12/2026), vital signs and labs from the 03/10/2026 visit were reviewed by the physician, who communicated no acute medical concerns and recommended monthly monitoring." Attribute; do not interpret.
Client-reported physical symptoms: dizziness, fainting, palpitations, cold intolerance, hair loss, menstrual changes, GI symptoms — documented as self-report and, when new or concerning, documented as referred to the medical provider with the date you made the referral.
Monitoring plan: who weighs the client and how often, who monitors vitals and labs and how often, how abnormal findings will be communicated to you, and what findings would trigger a level-of-care re-evaluation.
Escalation trail: any occasion you urged urgent or emergency medical evaluation, and the outcome. If a client reports symptoms such as fainting or chest pain, the defensible record shows a same-day referral to medical care, not a therapist's reassurance.

Psychiatric History and Comorbidity

Document co-occurring depression, anxiety and OCD-spectrum symptoms, trauma history, substance use (including appetite-suppressant use of stimulants and nicotine), self-harm, and prior psychiatric treatment. Comorbidity is the rule rather than the exception in eating disorders and materially affects treatment sequencing.

Risk Assessment

Beyond medical risk, document suicide and self-harm risk explicitly — ideation, plan, intent, means, history of attempts, and protective factors — using the same rigor as a standalone risk assessment. Also document risk behaviors specific to this population: driving while syncopal-symptomatic, insulin omission, ipecac or stimulant misuse, and exercise despite injury.

Mental Status Examination

Include a focused MSE. Common findings worth documenting precisely in this population include cognitive effects of starvation (impaired concentration, rigidity, preoccupation with food), affective constriction, and the quality of insight into illness severity — often the pivotal finding for level-of-care reasoning.

Family, Social, and Functional Context

Document family attitudes toward food and weight, family history of eating disorders or obesity-related stigma, mealtime dynamics, athletic or aesthetic performance contexts (dance, wrestling, gymnastics, modeling), social withdrawal around food-centered events, and academic or occupational impact. For adolescents, document caregiver observations as a distinct data source.

Diagnostic Formulation

Map findings to DSM-5-TR criteria for the diagnosis under consideration — anorexia nervosa (restriction leading to significantly low weight, fear of weight gain or behavior interfering with gain, and disturbance in the experience of body weight/shape), bulimia nervosa (recurrent binge episodes with recurrent compensatory behavior and overvaluation of shape and weight), binge-eating disorder (recurrent binges with marked distress and without regular compensation), ARFID (restrictive intake with nutritional, weight, or psychosocial consequences in the absence of body-image disturbance), or OSFED. Document the specifier and severity using DSM-5-TR conventions, the evidence for each criterion, and the differentials you considered — including medical causes of weight loss, which is another reason the medical evaluation belongs in the record.

Level-of-Care Recommendation and Treatment Plan

Document the level of care recommended and the reasoning: medical status as communicated by the physician, symptom frequency and trajectory, psychiatric risk, prior treatment response, motivation, and support system. Name the treatment approach (e.g., CBT-E, FBT, DBT-informed), the team composition (therapist, physician, dietitian, psychiatrist), and the reassessment interval. This links directly to the eating disorders treatment plan.

Eating Disorder Assessment Example (Completed Sample Write-Up)

The following filled-in example is entirely fictional and shows a completed outpatient assessment for a college student with a restricting-type presentation.

Eating Disorder Assessment — 19-Year-Old with Restrictive Presentation

Client: J.T., 19-year-old female college sophomore | Dates of Evaluation: 03/10/2026 and 03/17/2026 Referral Source: University health center physician | Evaluator: [Name], LMFT

Referral & Presenting Concerns: J.T. was referred by Dr. Alvarez at the university health center after a routine visit documented weight loss since her fall physical and the client disclosed skipping meals. J.T. states she came "mostly because Dr. Alvarez and my mom are worried," and describes her own concern as "I get dizzy in class and I can't concentrate." Her mother (collateral phone contact 03/12/2026, with signed ROI) reports J.T. ate progressively less over winter break, refused former favorite foods, and became distressed when meals were unplanned.

Weight & Eating History: J.T. reports her weight was stable through high school. She began "eating clean" in September 2025 after a roommate started a diet, progressively eliminating desserts, then carbohydrates, then most fats. Current reported intake (24-hour recall): black coffee; a plain rice cake mid-morning; salad with undressed vegetables at lunch; steamed vegetables and a small portion of plain chicken at dinner, eaten alone in her room. She reports rules including no eating after 7:00 p.m. and chewing each bite a fixed number of times. She denies binge eating, self-induced vomiting, and laxative or diuretic use. She runs 5–6 miles daily "no matter what," including one occasion running with a rolled ankle. She weighs herself each morning and reports intense distress on days the number rises. Per Dr. Alvarez's office, weight measured 03/10/2026 reflects a significant decline from the September 2025 visit; the physician characterized the current weight as significantly low for her height and age. J.T. reports her last menstrual period was in December 2025 (reported to physician).

Screening Instruments: EDE-Q (03/10/2026): global score in the clinically elevated range, with highest elevations on Restraint and Shape Concern subscales. PHQ-9 = 13 (moderate). GAD-7 = 11 (moderate). C-SSRS screen: denies current suicidal ideation, plan, or intent; denies history of attempts. Scores were interpreted alongside interview, collateral, and medical data.

Medical Coordination: ROI signed 03/10/2026 for Dr. Alvarez (university health center) and campus dietitian. Per Dr. Alvarez (phone consultation 03/12/2026), the 03/10/2026 medical visit included vital signs, orthostatic measurements, and laboratory studies; Dr. Alvarez communicated concern regarding weight trajectory and orthostatic symptoms, stated the client is currently appropriate for outpatient management with close monitoring, and scheduled weekly medical visits for weight and vital-sign monitoring. Client-reported physical symptoms documented and referred to Dr. Alvarez: dizziness on standing, cold intolerance, hair thinning, amenorrhea since December. Agreed monitoring plan: weekly blind weights and vitals at the health center; Dr. Alvarez's office to notify this clinician of significant findings; this clinician to notify Dr. Alvarez of behavioral escalation. This clinician advised J.T. to seek same-day medical care if she experiences fainting, chest pain, or palpitations; J.T. verbalized understanding.

Psychiatric History & Comorbidity: No prior mental health treatment. Reports lifelong perfectionism and high academic standards; describes checking completed assignments "three or four times." Moderate depressive symptoms with onset after the weight loss began — low mood, social withdrawal, poor concentration. Denies substance use; denies self-harm history.

Risk: Denies suicidal ideation, plan, and intent; denies self-harm. Primary risks are medical (monitored per plan above) and behavioral: compulsive exercise despite injury and driving to campus despite dizziness episodes. J.T. agreed to pause running pending Dr. Alvarez's guidance and to avoid driving on days she experiences dizziness; both agreements documented and to be reviewed weekly.

Mental Status Examination: Alert and oriented x4. Appears thin; dressed in loose, layered clothing. Cooperative but guarded when discussing food rules. Speech normal in rate and volume. Mood "stressed and foggy." Affect anxious and constricted. Thought process linear with marked preoccupation with food, calories, and academic performance. No perceptual disturbance. Concentration mildly impaired by observation and self-report. Insight limited: acknowledges dizziness and concentration problems but states "everyone is overreacting about my weight." Judgment fair to limited, as evidenced by exercising on an injured ankle.

Family & Social Context: Supportive family; mother closely involved. Roommate diet culture is an ongoing exposure. Increasing avoidance of dining halls and food-centered social events; grades declining from A to B-/C range this semester.

Diagnostic Formulation: Presentation is consistent with DSM-5-TR anorexia nervosa, restricting type: restriction of intake leading to significantly low body weight (per physician assessment), intense fear of weight gain expressed through rigid rules and distress at weight increases, and overvaluation of shape and weight with limited recognition of the seriousness of the current low weight. Medical contributors to weight loss were evaluated by Dr. Alvarez, who communicated that findings are consistent with the eating disorder rather than an alternative medical cause. Differentials considered: ARFID (ruled out — body-image disturbance is prominent), bulimia nervosa (no binge/purge episodes reported or indicated by collateral), and primary depressive disorder with appetite loss (depressive symptoms followed, rather than preceded, the restriction). Comorbid: moderate depressive symptoms, to be reassessed with nutritional restoration; perfectionistic/obsessive traits noted for monitoring.

Level of Care & Recommendations: Outpatient treatment is appropriate at this time per the treating physician's assessment, contingent on the weekly medical monitoring plan. Recommendations: (1) weekly individual therapy using enhanced cognitive behavioral therapy (CBT-E) with early focus on regular eating and psychoeducation about starvation effects; (2) weekly medical monitoring with Dr. Alvarez as arranged; (3) nutrition counseling with campus dietitian, referral placed 03/17/2026; (4) psychiatric consultation to evaluate comorbid depression once nutritional status is addressed, per team discussion; (5) parental involvement with client consent — mother to join a session in week 3; (6) level-of-care re-evaluation at week 4 or immediately upon physician report of medical instability, whichever comes first. Client verbalized ambivalent agreement: "I'll try, but I'm not promising to gain weight." Prognosis discussed with client; motivation and insight to be addressed as early treatment targets.

Evaluator: [Name], LMFT — 03/17/2026

This is a sample for educational purposes only — not real patient data.

Try this template in My Clinical Writer Download Blank Eating Disorder Assessment Template (.docx)

How to Complete It Step by Step

Step 1: Establish the medical track before or alongside the psychological track. At the first contact, get the ROI signed for the client's medical provider and confirm when the last medical evaluation occurred. If there is no medical home or no recent evaluation, document your referral for one and the timeline you set. In a restrictive or purging presentation, the assessment is incomplete until the record shows who is monitoring physical status.

Step 2: Take the eating history non-judgmentally and concretely. Use a 24-hour recall and behavior-specific questions ("How many times in the past month…?") rather than labels ("Do you binge?"). Clients minimize less when questions are matter-of-fact and normalized. Document behaviors with frequency, recency, and duration — those numbers drive both diagnosis and severity specifiers.

Step 3: Gather collateral wherever consent allows. Family members, prior treaters, and the referring physician routinely hold information the client minimizes. Document each collateral source, the date of contact, and what they reported, keeping it clearly attributed and separate from self-report.

Step 4: Administer and document standardized measures. Score, date, interpret, and integrate. If a score conflicts with the interview (a common occurrence with denial-prone presentations), document the discrepancy and your reasoning rather than silently privileging one source.

Step 5: Document client-reported physical symptoms as referrals, not findings. When a client reports dizziness, palpitations, or fainting, your note should show the symptom, the date you referred it to the medical provider, and any urgency guidance you gave. Never document reassurance about a physical symptom — that is a medical judgment outside your scope.

Step 6: Write the medical coordination section with attribution. Every medical fact in your assessment should carry a source and date: "per Dr. [name], [date]." This keeps your document accurate, keeps you inside your scope of practice, and creates the defensible record of coordination.

Step 7: Complete the diagnostic formulation with criterion-level evidence. For each DSM-5-TR criterion, cite the specific evidence — behaviors, scores, collateral reports, physician-communicated findings. Address differentials explicitly, including the medical differential, and document the specifier and severity.

Step 8: Close with a level-of-care rationale and a monitoring plan with triggers. State the recommended level of care, the reasoning, and — critically — what would change the recommendation: specific physician-reported findings, behavioral escalation, or failure to progress by a named review date. An assessment that names its own re-evaluation triggers is far stronger in an audit or adverse-event review than one that simply says "outpatient therapy recommended."

Common Mistakes

A record that is silent on medical monitoring. The single most damaging omission in eating disorder documentation is the absence of any medical coordination in a restrictive or purging case. Even when the client is medically stable, the record must show how you know that — who evaluated, when, and what the monitoring plan is.
Documenting medical interpretations instead of medical communications. Writing "labs were normal" or "vitals were fine" in your own voice implies you made a medical judgment. Write "per Dr. [name] (date), the physician reported no acute concerns from the [date] visit." Attribution is the difference between coordination and practicing outside your scope.
Recording only current behaviors without trajectory. Eating disorders are diagnosed and risk-stratified on course, not snapshots. Weight trajectory, behavior escalation, and the interval since the last binge/purge or the onset of restriction all belong in the assessment.
Treating denial as absence of illness. "Client denies body-image concerns" alongside a physician-reported significant weight decline and family reports of food refusal is a discrepancy to document and reason about, not a reason to defer diagnosis. Limited insight is a finding — document it as such and factor it into level-of-care reasoning.
Omitting the compensatory-behavior inventory. Asking only about vomiting misses laxatives, diuretics, diet pills, insulin omission, fasting, and compulsive exercise. Document each behavior asked about — including the negatives — so the record shows a complete inquiry.
No named re-evaluation triggers. "Continue outpatient treatment" without stating what would prompt a higher level of care leaves you exposed if the client deteriorates. Name the review date and the specific findings — physician-reported instability, behavior escalation, failure to progress — that would trigger re-evaluation.