Weekly Check-in Form — Adult · R.E.S.T.O.R.E. MNT

Please read carefully before signing

A weekly check-in is something I may suggest at some point in your care — not something every client needs, and not something we’ll start without talking about it first. This letter walks you through what a check-in is, what it asks of you, and why I might bring it up, so that if it comes up, you already have a sense of what you’re deciding about. After you read through, tell me below where you land — a full yes, a soft “not yet,” a clear no, or a “let’s talk about it more.” Any answer sends a note to me — I’ll see it either way.

How the Weekly Check-In works

This page is your consent to the Weekly Check-In — not the check-in itself. If you and I decide it’s part of your care, my team will upload a fillable check-in to your Healthie portal each Monday. You fill it in during the week — a little at a time or all at once — and return it through Healthie, email, or bring it to our next session before we meet.

A letter to you

What a check-in really is

If a check-in feels right for this season of your care, we’ll build it together — and I mean together. It’s not a report card, not a food journal to hand in, and definitely not a test. It’s really just a way for me to stay close to what your days are actually like, so that when we sit down together, I already have a sense of where you’ve been and we can spend our time on what matters to you.

I want to be honest with you: keeping a check-in through an eating disorder asks something real of you. There will be days when it’s the last thing you feel like doing, and there will be parts of the ED’s voice that whisper skip this one, round down, nobody needs to see that part. If that happens — and it will — please know it’s not you being weak, or lazy, or bad at recovery. It’s the illness doing exactly what illnesses do. Your job isn’t to outmuscle that voice on your own. Your job is just to let me see what came up, so we can take it on together.

Why the real story helps

What I’m actually looking at

When I’m reading your check-in, I’m not grading anything. I’m trying to get a picture of how your week actually went — the kind of picture that helps me be useful to you. Things like:

How meals actually landed — what felt doable, what didn’t, where the plan and real life lined up or pulled apart
How your body’s been answering back — energy, hunger and fullness, digestion, sleep, mood, cycles if that applies to you
What the ED tried to do — restriction, bingeing, purging, exercise pressure, rituals, rules, skipped meals, avoidance
What life was throwing at you — travel, big events, work pressure, emotional stuff, a grocery run that didn’t happen
Where things are going right — meals that felt okay, small moments of flexibility, anything that worked

Here’s the quiet truth: the parts you’re tempted to leave out are usually the parts I most need to see. Not so I can react. So I can understand. A check-in that only holds the “presentable” days tells me less than a check-in where the hard days show up honestly.

Day-to-day

How this might look

Find a quiet few minutes in your day that tend to be the same — maybe right after lunch, maybe before bed. Filling it in close to when things happened tends to be kinder on your memory than trying to piece a whole day together later.
Write what actually happened, not what you meant to do. If the plan and your real day didn’t match up, that’s okay — that gap is part of what we’re looking at together.
If a day gets away from you, just write “skipped” and keep going. Please don’t go back and rebuild yesterday from memory. A gap tells me something true; a reconstructed page tells me something smooth.
The reflection space is yours. Notice a pattern? Something you want to bring up next session? A small win? A rough one? Write whatever feels real. You don’t have to make it sound like anything.
Send it to me at kristine@sinnergywellness.com before our next time together, or just bring it with you.

About the hard parts

When it’s hard to be honest

There will be moments when part of you wants to soften what’s on the page — round a number down, leave something out, write the version I’d rather read. I want you to know two things about those moments.

First, they aren’t about me. Ever. That pull to edit isn’t about disappointing me or getting in trouble or failing a test. It’s the ED doing what it does best: trying to keep certain things in the dark. I’d so much rather hear about a rough meal than read a page where everything looks fine.

Second, you’re allowed to just say that. “I don’t want to write down what I ate today” is a perfect check-in entry. So is “I’m not sure I can be honest about this one yet.” Those sentences tell me something is happening, and that’s enough for us to work with. You don’t have to have it all figured out before you write it down.

Where it lives

Your privacy, clearly

Your check-in lives in your chart, inside Healthie, protected by HIPAA the same way anything else we talk about is. I don’t share it with your partner, your family, another provider, or your insurance without a Release of Information you’ve signed. If you decide at some point you’d like a support person looped in, that’s yours to choose and yours to change your mind about — any time, for any reason.

Your response to this recommendation

A check-in is not required for every client — I will discuss whether it’s right in this phase of care. Please indicate my response below. Kristine will be notified of my choice either way.

✓ Yes — let’s do this together

I’ve read through, it sits right with me, and I’m ready to check the boxes below and sign.

⏸ Not yet — I’d like to wait a little

Something in me isn’t ready for this step right now. I’d rather come back to it later, when I feel more settled or when Kristine and I agree the timing is better.

✗ Not right now — I’d rather not start a check-in

I’ve read this through and this isn’t the right fit for me at the moment. I’d like to keep working together in other ways and Kristine can reach out so we can talk.

💬 I have questions — let’s talk about it first

I’m not ready to say yes or no yet. I’d like to bring this to our next session and hear more.

Anything you’d like me to know (optional)

What we’re agreeing to together

If you’ve chosen to go ahead with the check-in, tap each one below to let me know you’ve read it and it sits right with you. All five before you send.

✓

I’ve read through the sections above, and I have a sense of what the check-in is and how Kristine will use it in our work.

✓

I’ll do my best to be honest on the page — including the behaviors, the hard days, and the parts that don’t feel shareable. I get that those are often the most useful parts.

✓

I’ll try to fill it in each day, close to when things happen rather than rebuilding skipped days later from memory.

✓

I’ll send my check-in to Kristine before each session, or bring it with me.

✓

I know my check-in is part of my chart, protected by HIPAA, and won’t be shared with anyone without my written okay.

Your signature

Signing here just tells me you’ve read through this, it sits right with you, and we’re on the same page.

Printed name *

Date *

Signature *

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