New Client Application - Pivot Nutrition
Please answer these questions to submit your application to work with me! If you have any questions, feel free to email Laura at
Date of Birth
What are you looking for help with? Check all that apply.
Heart Healthy Nutrition
Sustainable Health Habits
Accountability & Emotional Support
Learning what my body needs
General Nutrition & Wellness
Corporate Wellness Seminars
What are your biggest challenges with food/nutrition and eating habits?
What are your biggest challenges with healthy lifestyle habits (fitness, sleep, stress management, etc.)?
What payment method do you plan to use?
Health Insurance - Blue Cross Blue Shield
What days of the week are you available for meeting? Check all that apply
What times of day are you available to meet? Check all that apply.
Early Morning (7:30-9:30am)
Late Morning (9:30am-11:30am)
Late Afternoon (2pm-4pm)
Early Evening (4pm-6pm)
Late Evening (6pm or later)
Would you be open to a group coaching program?
No- I only want 1:1
Group support could be cool! But I do want some 1:1 support too.
I'd like more info on the group option!
I'm not sure what's right for me.
If weight loss is your goal, rather than focusing on just the scale, are you willing to take an approach that focuses on sustainable, realistic behavior change and mindful eating?
If we decide we're a good fit to work together, would you be ready to make a premium investment in your health?
Very Ready: I know that investing in my future health is what I need and I am ready to reach my goals!
Somewhat Ready: I'm figuring out if this is the right investment but I do want to make changes.
Not Ready: I'm not in a place where I feel like I can invest in my health goals right now.
What is the best way to reach you? Check all that apply.
If you plan to go through Blue Cross health insurance, please provide your address, Insurance name, ID#, and group number (if applicable) and I will check to see if your appointments are covered!
Please describe any additional helpful information you'd like me to know (including more info on your goals/history, and if anyone else is involved in the decision-making process).
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