Prospective Client Form
Thank you for your interest in working with us! This form requests some basic information in an effort to learn more about your needs and preferences, so that we can best match you with someone on our team.

If you are filling this out on behalf of a minor and/or a loved one, please note that at the bottom. 

All information shared will be kept confidential. 

Please note, we do not accept insurance. Some of our clients do receive out of network reimbursement. More information about payment options can be found here on our website: https://www.lknutrition.com/services.
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Email *
Name: *
Pronouns:
Cell Phone #: *
Age: *
City and State in which you reside: *
How did you find our practice, or by whom were you referred? *
In 1-2 sentences, what are your goals for nutrition counseling?
What qualities are you looking for in a dietitian/nutritionist?
Are there any meaningful identities you hold that you would like to share? (e.g., race, gender, ethnicity, religion, sexual orientation, body size, disabilities, or anything else)
Do you have a preference for in person sessions, virtual sessions, or a combination of the two?  *
Required
Are there any particular days of the week, or times of day that you prefer to meet for an appointment? And/or, there any days/times you definitely cannot meet? 
Do you have Medicare? (Please note, this is different than *Medicaid*). If so, we may need to send you an additional form to complete. *
Is there anything else you would like us to know or keep in mind?
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