New England Nutrition & Exercise Coaching Application
Thank you for reaching out! I will follow-up with an email on next steps for scheduling within 1-5 business days. 
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What is your First and Last name?
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What is a good Email to reach you? 
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What is a good Phone Number to reach you?
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What is your Date of Birth?
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How did you hear about New England Nutrition and Exercise?
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What sport(s) do you participate in? *
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What are your top endurance sports nutrition goals (pick 1-3) that you'd like to achieve by working together?
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What are your top challenges that are preventing you from reaching your nutrition goals at this time?

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On a scale of 1-5 (1= not ready at all, 5= most ready I've ever been), how ready are you to start making changes to reach your goals?
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Not ready at all
Very ready
My 1:1 sports nutrition coaching provides individualized support to help you reach your goals. My nutrition coaching has changed lives by decreasing gastrointestinal issues, increasing energy, improving performance and feeling better overall with a healthy relationship with food and body.

Payment: I am in-network with major health insurances. Everyone's plan is different and it is your responsibility to know your health insurance coverage. In order to bill insurance, a referral with a nutrition-related diagnosis code is required, even if your insurance says otherwise. 

If you do not have a nutrition-related diagnosis, payment will be self-pay for nutrition coaching.

My rates are $200 for a 55-min initial and $200 for 45-55 minute follow-ups. (If insurance denies your claim or if you are self-pay). On average, I see athletes at least 6 times to solidify education and habit forming change to reach your goals. This could look like two nutrition sessions a month for at least 3 months. 

Are you in a place to commit to this?
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What nutrition services are you interested in? *
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If you have insurance, who is your carrier? i.e. Blue Cross Blue Shield of New Hampshire HMO. 

If you don't have insurance, type in "self-pay". 
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What days/times are you available for nutrition consultations? My appointment times are between 8:30-11:30am and 2:00-5:00 PM EST Mon-Thurs.  *
What state are you located in? I.e. New Hampshire, Colorado, etc.  *
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