Nourished with Kindness

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Thank you for your interest! Please fill out the form below and we will respond within 1 business day. Please note that all potential clients need to complete this form, so it's the best way to get started!

Full Legal Name of Client, Pronouns, and Age *

Name of person filling out form (if different than client)

Email for person completing out form *

Phone number for person completing form *

What method of communication do you prefer for scheduling?

Phone call

Text

Are you (person completing the form) over 18? *

Yes

Where did you hear about us? (If it's another provider, like a therapist or an MD, please give us their name.) *

Which one of our specialties are you interested in? *

Eating Disorders / Disordered Eating

Intuitive Eating

Womxn's Health (pregnancy, fertility, postpartum, hormone balance, PCOS)

Food stress and anxiety

GI Health

Other:

Required

What are your top goals for working with a dietitian? *

Nourished with Kindness' approach is improving overall wellness, rather than focusing on weight (i.e., a weight-inclusive, Health At Every Size aligned approach). *

I understand.

I have a few questions on this approach and would like to have a brief discovery call to discuss.

What is your availability for appointments (if any limitations)? Please use Pacific Time and use the "Other" category for any specifications like "Only mornings on Tues/Thurs". *Please note that our Late Afternoon/Evening appointments are the most requested and limiting to those timeframes will require a longer wait time. *

Morning (8 am - 12 pm Pacific)

Early Afternoon (12 pm - 3 pm Pacific)

Late Afternoon/Early Evening (3 pm - 6 pm Pacific)

Anytime, I'm flexible.

Other:

Required

Which do you prefer? (Check all that apply) *

Virtual appointments

In-person appointments at our office in Thousand Oaks, CA

In-person appointments at our office in Eugene, OR

In-person appointments at our office in West Los Angeles/Santa Monica

I'm open to either virtual or in person depending on the first availability

Required

Do you have a preference for which RD you would like to work with? (Please do not choose only one RD.) *

Alyssa

Brooke

Colene

Drew

Jessica

Katie

Kayla

Kelley

Madalyn

Michele

Natalie

Sasha

I'm open, I'll work with the first RD available

Required

As dietitians, we need to get a referral from another health care provider for our services (regardless of whether your insurance says you need one). Are you able to work with your team to get a referral emailed/faxed to us? *

Yes

I also need recommendations for a doctor or therapist to get a referral.

What is the date of birth of the client? *

YYYY

What is the address of the client that is on file with their insurance? (Please include city, state, and zip code.) *

What insurance carrier and plan do you have? *

Anthem Blue Cross PPO (NWK is in-network with many plans)

Aetna PPO (NWK is in-network)

Blue Shield of California PPO (NWK is in-network)

Cigna PPO (NWK is in-network)

UnitedHealthcare PPO (NWK is in-network)

HealthNet PPO (NWK is in-network except for Ambetter plans)

Multiplan PPO (NWK is in-network)

I have an HMO (NWK is NOT in network)

I have Kaiser, Medi-Cal, Medicare or another insurance plan. (NWK is NOT in network) Please specify plan in the next box.

Please provide your Member ID number and Plan type (if you have it, ex: HMO vs PPO vs Other). Also please provide the primary insured's name and date of birth if it is not the client. If you have multiple insurance plans, please list ALL plans and indicate which plan is primary. *

Have you ever been diagnosed with any of the following? Please check ALL that apply. *

Anorexia, Bulimia, Binge Eating Disorder, Avoidant Restrictive Food Intake Disorder (ARFID), or other Eating Disorder diagnosis

High Blood Pressure or Hypertension

High Cholesterol or Hyperlipidemia

Family History of Heart Disease (including any family members with high cholesterol, high blood pressure, or any heart issues)

Pre-diabetes

Diabetes

Elevated glucose or A1C

PCOS (Polycystic ovary syndrome)

Mental health diagnosis (Please specify in Other)

Other:

Required

Is there anything else you want us to know? (Are you preparing to step down from treatment? Do you have a tentative discharge date?)

Are you ready to schedule your initial assessment? *

Yes

I have a few insurance questions that I would like answered first on a 15-minute call.

I have a few general questions that I would like answered first on a 15-minute call.

Please confirm that you understand that you will need to email or text us with a copy of your insurance card (front and back), provide information on the primary insurance holder (name and DOB), and indicate which plan is primary (if applicable). *

Yes

I am not planning to use my insurance benefits.

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