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.

All information you share will be kept confidential. Questions marked with an asterisk are required, and the others are optional.

*Please note, we do not accept insurance, but some of our clients do receive out of network reimbursement. More information about payment options can be found here on our website:
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Email *
Name: *
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 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, or anything else)
Currently we are only offering virtual sessions. Once we resume in-person sessions, at which location(s) would you be willing/able to meet? Choose all that apply. *
Are you open to working with a provider on our team who would only be able to see you virtually, or would you only prefer to be matched with someone who would be able to eventually see you for in-person sessions? *
Are there any particular days of the week, or times of day that you prefer to meet for an appointment? If so, please share below. Also, please share if there are 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? If so, please share below.
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