Thank you for applying to work with us!! 
Hey there, 
we are happy you are here!  
We love helping people find a better relationship with food and eating! If you are interested in working with Rebecca, Taylor or Brynna,  please fill out the survey below and I will get back to you!
Full Name *
Age *
Best way to contact you (cell,text,email)
What state do you live in? *
Which health insurance do you have? *
What are your main reasons for seeing a dietitian? *
Are you currently receiving therapy for an eating disorder? If so, please list which disorder you are struggling with and who/where you are receiving treatment  *
On a scale 5, how motivated are you to change your relationship with food?
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Which dietitian are you looking to work with? 
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Is there anything else you'd like to share with us? 
How did you hear about us? *
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