FEDUP Dietitian Request Form

Request edit access

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For our community to request support to see deeply sliding scale dietitians ($0-$25/session)

Name *

What are your pronouns?

How do you describe your gender?

What city and state are you located in? *

What is your email? *

What is your phone number? *

At this time, most dietitians in our matching program are cisgender white women. We are actively seeking additional participants, however in order to provide you with care in a timely manner, are you open to a cisgender white dietitian or would you prefer to wait for a dietitian who meets more specific criteria? *

I am open to being matched with a cisgender white woman.

I prefer to wait

If you prefer to wait for a dietitian with different background or identities, what are the criteria you prefer?

Do you currently see any medical or mental health professionals? *

Yes

Please describe what type of professionals you are currently seeing if comfortable. (this will not impact your request)

Do you have health insurance, and if so, which plan? (Health insurance isn’t not required, it will simply allow some of the dietitians we are pairing people with to be matched with more than one person.) *

How much can you afford to pay per session? (Can be $0, if applicable!) *

What are you looking for help with from a dietitian? *

Please include any details about yourself or medical conditions you have that impact your nutrition that may help us match you with a dietitian (i.e. PCOS, diabetes, celiac disease, food allergies, etc.)

Do you have any access needs? (i.e. ASL interpretation, captioning, telehealth only, etc.)

Are you over 18? (This does not disqualify you.) *

Yes

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