New Client Questionnaire
Stanton Nutrition Counseling, LLC     
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Name of person completing this form: *
Name of prospective client  (If different from the name above, please share your relationship with this person)
Client age *
Phone number (if filling out this form for a minor client, please list your number) *
Email address (if filling out this form for a minor client, please list your email address) *
How did you hear about us? 
Which do you prefer?  *
Please select the area(s) in which you wish to receive support. *
Please provide additional information about the specific diagnosis, concern, or nature of the problem.  *
Please read carefully: Stanton Nutrition Counseling, LLC is an insurance-based practice and can bill in-network insurance providers for services provided. Even if you do have insurance, according to your specific plan, you may have a cost share (i.e. deductible, co-pay, etc) that applies or services may not be covered. You are responsible for knowing your benefits, but we are happy to help you navigate finding out this information before scheduling an appointment. If you do not have insurance or have insurance that considers our providers "out of network," you are responsible for payment at time of service. You may use your HSA or FSA to pay for services. A superbill can also be provided upon request to submit to your insurance provider for reimbursement.  *
If you plan on using insurance, please check your insurance provider(s). Note - we are only in network with those listed below.
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When is your availability for appointments? (check all that apply)
Are you in need of any accommodations for an appointment (i.e. wheel chair accessibility, interpretation services, need to bring a service animal, etc)?
Anything else you would like for us to know prior to contacting you to set up an appointment?
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