Nutrition Elevated, PLLC Prospective New Client Form
Hello! Thank you so much for your interest in working together. Please fill out this HIPPA-compliant form and I will get back to you within 48 business hours.
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First and Last Name *
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? *
Of note, all visits are only offered virtually as of now
Required
Are you reaching out on behalf of yourself or a child? *
If you are reaching out on behalf of a child, how old are they?
Why are you interested in nutrition counseling? *
Have you been diagnosed with an eating disorder? *
If you are struggling with an eating disorder, are you currently seeing an eating disorder therapist? *
Did another provider refer you to my services? If so, who referred you? *
Are you aware that I am out-of-network provider? *
Confirm that you have read the FAQ's on my website: https://www.nutrition-elevated.com/appointment-information/ *
Required
Thank you so much! I will reach out to you within 48 business hours.
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