Nutrition Elevated, PLLC Prospective New Client Form
Hello! Thank you so much for your interest in working together. My practice is currently full, but please continue filling out this form to be added to my waiting list.
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My practice is currently full. Would you like to be added to my waiting list? *
First and Last Name *
If you are reaching out on behalf of your child, please include your full name here
Email Address *
Phone number *
City and State (please note that depending on where you live, we may or may not be able to work together due to state licensure laws) *
Are you interested in virtual or in-person visits? *
I am now offering in-person visits on Mondays and Tuesdays at my office in Wallingford to clients who can provide proof of full vaccination.
Required
Are you reaching out on behalf of yourself or a child? *
What is your child's name? *
If you are reaching out on behalf of a child, how old are they? *
Why are you interested in nutrition counseling/why are you reaching out on behalf of your child? *
Have you (or your child) been diagnosed with an eating disorder? *
If you (or your child) are struggling with an eating disorder, are you (they) currently seeing an eating disorder therapist? *
When would you (and/or your child) be available for regular visits? *
(Check all that apply)
Required
Did another provider refer you to my services? If so, who referred you? *
Are you aware that I currently accept First Choice Health, Premera Blue Cross, United Healthcare, and Regence but am an out-of-network provider for all other insurance companies? *
Confirm that you have read the FAQ's on my website: https://www.nutrition-elevated.com/appointment-information/ *
Required
Thank you so much!
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