Nutrition Elevated Prospective New Client Form

Hello! Thank you so much for your interest in working together.  As of July 2024, I have some availability in my schedule to see new ADULT (18yo+) clients. I currently have a waiting list for new TEEN (13-17yo) clients. If you are interested in working together, please complete the form below.

Once I receive your submission, I will get back to you within 72 business hours with either:

  • An email update with your place on my waiting list, OR
  • The link to schedule a complimentary 10-minute Meet & Greet video call.
Thank you!

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Are you reaching out on behalf of yourself or a child? 

**To ensure the protection of client privacy, Nutrition Elevated will not accept visit requests from parents or caregivers on behalf of their dependents (18 years and older). If your child is 18 years and older, they will need to contact Nutrition Elevated directly to establish care. At their first visit, we will discuss if they feel comfortable signing a HIPPA Release Form for parents/caregivers.
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How did you hear about my services? *
Required
If another provider referred you to my services, please share their name below: *
What is YOUR first & last name? *
Your Phone number *
Your Email Address *
What is your child's name? *
How old are you? (or your child) *
Please confirm that you agree to the following: for legal reasons, all clients must be physically located in Washington State for every nutrition visits, even virtual visits. *
Have you (or your child) been diagnosed with an eating disorder? *
Have you or your child ever been hospitalized for an eating disorder?  *
What are you (or your child) seeking support with? (Select all that apply) *
Required
Please include any additional details about why you are interested in nutrition counseling: *
Please check all that apply:
 *
Required
How motivated are you (or your child) to engage in treatment? *
Are you (or your child) currently seeing a therapist? *
Are you interested in virtual or in-person visits? *
Required
When would you (and/or your child) be available for regular visits? *
Required
Do you plan to use insurance or private pay? *
Please note, Nutrition Elevated accepts Regence, United, and First Choice Health. Please select an option below:
Confirm that you have read the Financial FAQ's and understand the following: *
Required
Thank you so much for taking the time to fill out this form! 
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